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Sep, 14. 2015 2:46PM GEORGE W LOWRY, INC No. 1175 „ P. 1
<br /> �E�rgs Form Ap roved.UNttsNo,20540039'x-;e print or type: Fprm.desigrred for use on ellte'.( 2 Itch) er.) �2P..U. of ncy Response Phone anifebt TrackinmbI,4
<br /> 1,Generator IP Number; 12473143 `JJ K 1
<br /> UNIFORM NpiZARDDUS
<br /> WASTE MANIFEST �: �A( � 7512•
<br /> S.Generelora`Nameand'Maihn Address' ' ; 'Generator'sSlteAddrass(iPdlfferentthanmallingaddress)
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<br /> Generator's Plioner.1 ' U.S.EPA ID Number
<br /> 6.Transporter I0'rnpenyName
<br /> U.S.EPA ID Number
<br /> 7,l7anaporlef2Cm1Y Name
<br /> U,S,EPA ID Number r
<br /> B.oosi .!. E(dVlri0M 65NTALHEALTI�
<br /> PERMITIS0VICES
<br /> Facilitys PhoneSr.i:;
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<br /> r Beit(Including Proper 5hi Name d• ate,ID Nurn¢ek,;;` .
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<br /> :'1'1 ""�!-•` - Y proper }n name,.grid are classified,
<br /> t5. GENlERA70R$IOFFEROR'3 CERTIFICA1lONt I hereby declare Ihat the contents of this consignment are fully and'accuratelydescdbed above b the ro er Shipp g p.
<br /> marked and lab 10,FF lar'OR1 snot are in all reaper is in proper wndiGpgfortransport,accordlpg to,applicable intemationa(and national govemmomal regulations:If axpon shipment and cam the Primary',
<br /> Exporter;I Ceri�`ahet the contents of this consignment conform to the terms of the aliached EPAACkr *edgmut f Cd I en a emelt quantity generator ie We.
<br /> I eerily that the waste minimizalfon statement identified in 40 CFR 202,27(a)(if I am a large quanity g ) O( 4 ) htonlh Day ',.yeaf
<br /> Signature y. t
<br /> General0l'sldNerofS'PrilltedlTyped Name
<br /> � 16.Inlema80nal Shipments Port of en le:ht:
<br /> Importto U.S. Q Exportira ri U,S, hY
<br /> orfs ant❑ Dale IeaJ�ng U,3,; '
<br /> TransparlerslgrittWfq(fgr:exP. Y)
<br /> W 1T.TraniporferACk 6o dsdgmenl of Receipt of Materials Month Da year • '`
<br /> Signature a Y'
<br /> Transporter t ypadN m.,
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<br /> N fff 3lgnalure . ..
<br /> Month Day„ year
<br /> Q Transpcder 2:Rrin ped ams )
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<br /> Ia.Discrepancy
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<br /> loot.Dlscrepancyi0dtoaonspace ❑ Quantity ❑l'ype El PaiBalRelectien QFullRelection
<br /> Manifest Reference Number:
<br /> • u.s.EPA Ip Number
<br /> tab,Altemete:FacPity(orgenerator)
<br /> 1. Facllfy's Phone: MonM. . Day Year
<br /> W 18c,signature afAliemala Fac%(or Generator)
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<br /> y 1g.Hazardous'Waale Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling Systems) 4
<br /> 3.
<br /> 20.Designated Facility Owner of Operator.Cerllflcalion Of receipt oP hazardous materials covereel'by the manifest except as noted in Item 18a MQnI Day Ye
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<br /> EPA Form 8100.22(Rev.3.65) Previous editions are obsolete. �'''' �' . 7pANSPOHTER'-i COPY
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