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Please Pint or type.(Form designed for use on elite(12•pitch)typewriter:) Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Ge eralor ID Ni?tnt o; 2.Pa}ge 7 of 3.Emergency Response Phane 4 Manifesf Tacking Number <br /> WASTE MANIFEST 0� , 3� 1 5 r f -c� 3 . 005232319 JJK <br /> ;6dratods Nave and Mailing Addie3, t� tioGaeraloYs S to AddmsS diforW than m vino address) <br /> P•cr.6c�c tKb9 t�.� �tn,eh��, R�•IGs►'�' �l <br /> Garter foes Phone ©s <br /> 6.Tren§odner I Company NameIJ,S.EPA fD Number <br /> . Transportor2 t - panyName - - <br /> U S EPAlD Number <br /> Vt °ll {�1. 1 � I OA <br /> r <br /> - B Designated Faci3ity Name and Site Address - - U.S.EPA ID Number I <br /> i �lh�QT(3►.� <br /> �auiii S Ptryfle. <br /> 9a. gb.t1:5 DOT Desaiption(inducting ProperShipping Name,Hazatd Ciass,iU Number, 10 Gontainers 11 Toch! 12.UnitryM and Packing GrouP(ifany)) - i3.waste CodesNo. Type Qoanbty WI.fVul, <br /> 1 I.f rZfog''�, ca}l� '\ t,E,pt -sSalmizj^ d,�- tookLLJ <br /> 2. <br /> tip ,�vyt <br /> t�}7 <br /> A Lw s►.ilr blr r [1LwA1G 1 <br /> -m 0)a-Qa5 f rll�p 0 0.S <br /> I <br /> 4 AUG <br /> t� <br /> 14.5petlatFtandling-Instructcnsand Additional Mronnation F .� <br /> 9�3 <br /> 71 -7 - <br /> 15 GEMERATt6 WOr-FERORr3:CffATIFICATZDN: I herebydedare that the conlerd of this CpmVnment are fully and acc ialely dasc&ecl abave by the proper shlpp€ng name,and are dass'rried,packaged, <br /> mmsfaed tmdl�ll9dplaeaiC9� iKt�t@ to al respects irepfopercond dors lar#artspoTtaceartlirtg_(g app40de international and natictriai governmental regulations.If export shipment and l am the Primary <br /> Expotw,I cer"Itlal Y1e oontalttsotttMa oftfunenl txiltforrn t0 flue terms of tho attached FJRp,At7mo 4iftmont of Consent <br /> I aariflY:101 ate waste rni imu:ow staW,wit Idenbfiad In 40 CFR 262.27(a)('d I am a large q „r)or(b)(d I am a small quantity generator)is true. <br /> G-naratof Prinfe rr ftrre a Month Day Year <br /> 16 lntematw zfShipments �--7 -- <br /> LJ lrnp6R to U.S. LJ Expartironi t.'.S. Pori of ehfrylexit: <br /> Transporter sgnature(for exports onfy): flats lean ng U.S. <br /> 17.TranspxterAcknoAp4rgenf of ReceipR Gr f4te6als <br /> .,Tran 1 S'nn IN me - Signatur - M:.flth D y Year <br /> Q rter2 W61q<VTy0ed1 Nunn ' Monlh i_tay Year <br /> lh attiret <br /> 18.Dtserepaeey <br /> 18a.Discrepancy Indioation Space Q Quandt-,; Type . .. �J Residue ❑Parrial Refei:Uon 1.--1 Fuil Re)edw <br /> Manifest Relorenco Number. I. <br /> 18b Alterhate Facifity(or Generator) U.S.FPA ID Numtiar <br /> U <br /> tai FaciiV6 Phone. <br /> Uj 1Pc.STgnatureofNtem7eFaciP'ity(orGenefalor) -Month Dav Year <br /> : 19.Hazardous VYasW Report Managernenl Method Codes(i.e,,oodes for hazardous waste tn?atnnenl,.disprsal and.re-ding systems) - <br /> 2d.gesk,}rtated FaplRy Qvirser:or Dp®rator GerlfftraAon or racreipt of hazat�aus matersaPs covered by Iha manifasd ax t as ri in item <br /> pnniedlfyp a. S;Snablry Month Day Year <br /> � // <br /> EPAForrnB700 (116w 3-05) Prey;ousedillorls'aid atssolusle. DESIGN ED FACILITY TO DESTINATION STATE(IF RE61JIRIvp) <br />