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urease pont w .(Form designed for use on e8te(12 ih:h)typewdw.) <br /> UNf ill FIAIARDous 1.Geremblr ID Number 2 Form APPmved.I No.2050.0039 <br /> WASTE MANIFEST 1=J — <br /> mse Phare 0.Nlaniiul mdrtrig Nrm�be <br /> S.GeneafoYs Nameand Madmg Adr6asa -•- <br /> eab(ifddferemdw maiGncGervel Phone: '.. �6. ansporkrlRP U.S.EPA ID Numi <br /> 7.Traraporter2CompanyName " <br /> U.S.EPA ID Numbs <br /> d Des9reteo Facr3lyNameand SiteAddress <br /> U.S.EPA ID Number <br /> ENVIRONMENTAL HEALTH <br /> Faddys PFpne: ;< ...: r-"=°'LTi ANT _ <br /> ga 9b.US.DDTD=r#*M(d+daig�ShOPmg Nene,Hama Class,ID Number, to.Cones „ r <br /> HM Packing Group(Vary)) 11.Total 12.Unit 13.Waste codes <br /> 1• _ No. TYPe CantitY WWoI. <br /> C . .. <br /> t— <br /> z 2 <br /> i <br /> 3. <br /> i <br /> I 4. <br /> I i + � •I <br /> I14.5pecial Handfmg lrehua5onsandAddAoral lnfamation .::.....:... . .ag..,;` ;;;.,....:,; �.. .. :-..,,:,.•..:. .... .a <br /> i <br /> X15. GENENAMR911CIFFERIDWSDERfIFICATIDN: Ihmbydedam Nalthe=tentsofth'soar,* mentmfu"i:lllvalelyl bmebytlrepmpr shippbg reme,and are classified,packaged, <br /> 1 ..w andl beledfplacarded,andaminalf, inprgwmnddimfortransponaa nkQtoapp5caNe intemationd anE national <br /> Barter,1081*that the Contens ofdis cons mmemmrdorm,bt Bre terns of the atladced EPAACImoxfiedgmemofConsent., 9ovemmerdal regulations Rexport stupmemandlam file Prbney <br /> I of Ihalthe wade mmtm dm sta�nrem iden66edin40,CkR 262.27(a)(df am awge quantity generakr)Opp(ill am asma0 quantity gm abx)sbue. <br /> Y O6ereY. .::.o-.nrp�Nenetignature <br /> Y <br /> 16.International Shiprnenis <br /> Z �Importb U.S. ❑Exponfrom U.S. �.....Portof enoy/aut. <br /> Transporter d for wal only): Date leaft U.S.: <br /> W 17.TrdrspmlerAdmoniedgmernofRecelptofMilitates <br /> Transporter 1 ypod Name sli <br /> Q Trani PrmtediTyped Name reaae I- <br /> O, Yea <br /> r- <br /> t18.Discrepancy <br /> 18a.Dsmepmcy lndol Spam 11 ��, ❑TYPe ❑Residue ❑Partial Rejection ❑Fuo Rejecfion <br /> 16b.Altenreta Faali!)'(a Gaieramr) Maned Re ereme Numb <br /> U.S.EPA ID Number <br /> V <br /> F s Phone: <br /> 18c srtyeW2 afAlfemzte FapTity(or Gererdtor) Month <br /> G Day Year <br /> Z <br /> W19.Hamdc s Wass Report Maragene t Metltod Codes(i.e.,Codes forhEmrdow vaso lleaMem,disposal,and recyd'mg sysial <br /> 01. 2 3. 4. <br /> 20.Designated Fal a operator:Certification of ra l of hamdous materiels oovered by the mal except as noted in Item ilea <br /> PmmTyped Name <br /> Signature Month Day Year <br /> PA Form 8700.22(Rev.3-05) Previous editions are obsolete. <br />