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e pnnl or type.(Form designed f'or use on elite(12-itch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1-Generator ID Number 2.Pagel cf 3.Emergency Response Phone 4-Manifest <br /> - ' 4ManifestTracking Nunr <br /> WASTE MANIFEST �� CO'� Zllq-©11-005232328 J J K <br /> S Generator's Name and Mailing Address Generators Sdde Address fittdifferen(than ma ling address) <br /> civ' H"A"4- tJA.V-- g4a6 <br /> cam- <br /> eralm's Phone: <br /> B Transpaftar i Company Name US EPA ID%mber <br /> t tai . f o %0.3S Rel C lam` CA-E 0 InL'\l <br /> .Transporter 2 Company Name - � - � U.S.EPA ID Numtw <br /> L ! <br /> B.Deslgnated Fadity Name and S e Address �, 3 y�i� � U.S.EPA dD Nufter <br /> FariiliEy's Phone: d'�t°3- 2`�•' �. ,� ��� O{ <br /> ga, 9b:U.S.DOT Desraiption(induding Proper Shipping Name,Hazard Class,lD Number. foJ Coniall m 11:Total 12.Urit 13.Waste Gxfes <br /> HM and iPadMV Group of any)) No. 'Type Quavery WI.PJoi. <br /> 3. i <br /> 2:tJiJ 3Z� GdrSt �- �ie C �c a �' ads ii,i(D h tz <br /> 331 <br /> 3. <br /> 4. i <br /> US 17 ME <br /> rl hboo* <br /> 14.Spacial FlandNV instructions and Addifional Information .1 l <br /> 15 GENERATOR'S}OFFEROR'S CERTIFICAMM.I hereby declare that the contents of this oonsignment are fully and aowmtety described above ty the proper shipping Mame,and are e3ass f ed,pact aged, <br /> mailed and iabelelplaarded,and arerrn all respeds in pmw condition for lranspnd accbrding to applicable int riationaiand nalionai govemmental regulations.If export sfidpment ane I art the Primary <br /> Expoder,t oertify ffiat the"terkw of this consignment eonluma to the terns of the attached.EPAAcknowiedgment of Corscnl. <br /> I ccr i f i ma waste minimb:Am statement identified m 40 CFR 262.27(aj(+f1 sm a large quantity „;, tor)or(b)(if l am a snwtl quantity generator)Is t'uo. <br /> Generalorsd4flemrs n[ ypedN Signa" micrlh Day Year <br /> 117 <br /> Ihternafidna Wpfhenls <br /> h l=Import to U.S. Export from U.S. Port of enbylegt _ <br /> Transporter Ognature(for expor%only). Dale leaWng U.S.: <br /> 11J <br /> 17.TransporterA6nw edgnwnfofRecepfotMaterRals <br /> Transporter S PjoiaWdlfypccl Na fie S g rah re Morb Day Yeer <br /> Tr ati rtar Z Frinledrryped Nm-sag * Momh Dar Yeaf <br /> L <br /> -22 <br /> 11 18.D€mepancy <br /> 1 Ba D sbepancy Incrcatro Space � 1i, <br /> ❑ Quantity !J Type L_7 Residue MAia!iPejecl:on ILE <br /> `I Flli Rejection <br /> Mandfest Refefanca Number <br /> 19h:Al4Mriate Fadity for Genatatef} !5 EPA iD Nrimber <br /> Facidriys Phone, <br /> 1Bc.5ignatiarr,of Alwralr:Ftoiay(�xC3a irralu�, Month Day Year <br /> 19,tfazardou9Waslo Report Management Method CMOs(i.e.,codes for hazardous erode lreatMent disposal,and recycling systems) <br /> 2 3, 4. <br /> 2(7. es gnaled Faulilj Omw or Operator:Certification of receipt of hazardous materials cowad by Ole menifesl ex pl as 0.d IOWA <br /> Pm . yped N 1 Signature Month Day Year <br /> _ { �p i7�'r l v �iir+�yGd� 711 <br /> EPA Form 19700-22(Rev.305) Prevkius editions area Mete. CDESIGN TED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />