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case print or type.(Formdesignedfor use on elite(12-pitch)typ ) Ah Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page t of 3.Emergency Response Phone .Manifest Tracking Number <br /> WASTE MANIFEST C a nYl!'"R` 'Yn'Fi 1 'O.S " '�N -a"d;A?ti 'd r' RS1 ^' •f. :'i""S FLE <br /> 5.Generatofs Name and Mailing Address Generators Site Address(g d'dferent than mailing address) <br /> Now GCXAv3T 6;O1w:S—z <br /> 77'.,'x'n�-'CM: TUrSL^w" <br /> Generators Phone 5f •i ;'Y - .i <br /> . mnsporteri uompanyNarae U.S.EPA 0 Number <br /> ifP..t'nhM1�' il0li:Mt(.1MY'iFCF `��ri t .. <br /> 7.Transporter 2 Company Namen rj q 2 U.S.EPA ID Number <br /> B:Desgnated Facility Name and SBeAddress .. F1 fY 4_ <br /> I AL <br /> US EPAID Nymber <br /> CN IIN19 sUC 1�9�116 11� TnRCN1T <br /> Facility's Phone: CA <br /> 9, 9b.U.S.60T Description(including Proper Shooing Name,Hazard Class,ID Number, y 10.Containers. 11.Total 12.Unci <br /> HM and Peddrrg Group(tt any)) Na. Type Quantity yN,!yci, 13.Waste Codes <br /> 0 <br /> 'NM RM HaARMUS'WASM,UQLM OLY WATL?lt) Tr � <br /> FIT <br /> $ � <br /> z2. <br /> W , <br /> 4. <br /> 14.Special Handling Instructions and Additional Information PN*d INIMber HIM DOW/1aIWi 010 - <br /> -1). ACf471%8R-_n <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and ars classified,packaged, <br /> marked and Iabeledlplaca ded;and are in all respects In proper condition for transport according to applicable international and national govemmental regulations.If export shipment and I am the Primary <br /> Exporter,,)certify that th@ gontents of this consignment conform to the tens of the attached EPAAcknowtedgment of Consent <br /> cans dtat 4smjtoAPn statement identified In 40 CFR 28227(a)(if I am a large quantity generator)or(b) am' gall quantity generator)is true. <br /> Gen tin me mom ua)�' r <br /> 98&-Intimation ipments <br /> Z .. Import to U.S. ❑Expod from .S. PAW <br /> Transporter signature for exports only): Date leaving U.S.: <br /> W 17.TranspodeiAdwviladgment of ReceiptpfMaterials <br /> Trenlhs�pbrter l Pdnte�df^rypetl Name -inn y gnature o1n / ay Year <br /> ! r P / YAM 1/f,4'� - ' �'-cE�C�T't/� '. Y ll.�;+.r^i}-A"z t,�C-+-. I y I/-S 16 - <br /> QTransporter Printed/fypedName 5ignatume Monty Day Year <br /> K <br /> 18.Discrepancy <br /> 18a.Discrepancy Indlcotion Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection - - <br /> Manifest Reference Number: <br /> 78b.Alternate Facility(or Generator) Manifest <br /> EPN9Nymhen •: + K cf. C <br /> J <br /> U <br /> LL FPhone: ' <br /> w <br /> in gnatureofMmate FecilRy(v Generator) Month Day Year <br /> z <br /> z <br /> h19.Hazardous Waste Repo anagement Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 3. 4 <br /> 20.Dasggak Facility/-Owner or Operator.Certification of recapof hazardous materials covered by the manifest except as gotedug Item 1 B <br /> PrintedRyPetl Name r r' Signature Yegr <br /> :PA Form 8700-22 Rev.3.05) Previous edRions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />