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Please print or We.(Form designed for use c i elite 12-pitch) qkr.) • Farm Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generehr ID Number 2.Page 1 of 1 3.Emergency Response Phone 4.Menihet 7}ackl Number <br /> WASTE MANIFEST - 2- _ 0 0 2 5 8 6 61 G B F <br /> mxQ4 Name and Melling Address Cf GeneraWls Sits Addmss(H different then mailing address) <br /> Le7AP /\ <br /> is-Y�cs s� <br /> Generators Phare: Rxkjvk <br /> x:.cicf <br /> B.Transporter 1 Company Name U.S.EPA ID Number <br /> retea RaC Z <br /> 7.Transporter 2 Comperry Name r U.S.EPA ID Number <br /> gne(Wd Ferai%y Name and Slle Pddress 17�d r U.S.EPA ID Number <br /> 3-n-o/\�$p �I6Ae� F6rlWo-dsy� Lc-'-A <br /> p <br /> Faa7 sPhone: Vc..s nWck c 09� aDas <br /> ge. Bis.U.S.DOT Description(Including Proper Shipping Nepro,Hazard Claes,ID Number, 10.Comer <br /> HM and PauNrg Group IVORY)) 11.Total 12.Unit 73.WasteCodes <br /> No. Type Quantity WtNol. <br /> c NCnv-P4ZftA FE^w dae8 Wade, SolsDs �OU p 3rz <br /> OiC o T -_ <br /> � 2' - <br /> L <br /> 3. MAT 24 �Ult <br /> rre"Fa. . �lrl" <br /> 4. <br /> 14.Special Handling Instructions and Add ml Information <br /> VJ�YkG Ppo(1t�t (/SPta�,Bsoiabtz��s <br /> 16. OENERATOR'SIOFFEROWS CERTIFICATION: I hereby declare that the contsnte ofthis consignment ere WM and ecaratey described above by Bre p DW sNpphg name,and are caul led,packaged, <br /> marked and IeheleNplacarded,and ars In all respects In proper cmdldcn for aamporl according to sp licabb international and national gwemrnental regulations.If export shipment and 1 am the Primary <br /> Exporter,l cedky that Bre contents of he consignment mnferm to the temps of the attached EPAAcknowecirvint of Consent <br /> I tartly that the waste mhimtrallon statement kientilled M 40 CFR 262.27(x)(k 1 am a large quantity generetor)err fl em a wall quer rotor)is true. <br /> alOSemrs PnntedRyPed Name Slgnefu Main Day Year <br /> Z 71// <br /> J 1&Irdemal l Shipments <br /> .pod ro U.S. ❑Export from U.S. Pod alentrylrotlt <br /> Transporterslgnalure(M exports only): Data tsedng U.S.: <br /> 17,TreaspaterAclaowledgmerd ofRecegl of Materiels <br /> Transporter i Pdnted/fyped Name Slg"Wm Month Day Year <br /> Dmo 16M N)q <br /> .dr. Transporter 2 dnWTypad Nemo Signawra tis Day Year <br /> .S 18.Discrepancy <br /> 16a.Discrepancy Indication Space ❑Residue <br /> Ouan6y Type Part Refection ❑Full Refection <br /> Manifest Reference Number. <br /> tab.Alternate Facility(or Generator) U.S.EPAID Number <br /> V <br /> ser+. Faclky's Phone: <br /> W 16G Sfgnebre of Alternate Facility(or Genersor) Month Day Year <br /> 2 <br /> S2 19.Heaamous Wash Report Management Method Cadet(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3, 4, <br /> 1 , Designated FacRy Omer wOperaror.C@Mcation of mmol of hmrdws ma*da s w Bred by th maNhsl except as Med In Item 18a <br /> MI yped Igneture Month Day year <br /> EPA Form 8700.22 .3D5) Previous ediBons are obsolete. <br /> DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />