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• <br /> Please print or type.(Form designed for use on eiile(12-pitch)typewriter.) ' Form Approved.OMB No.2050-0039 <br /> UNIFORMHAZARDOUS I.GenealorlD Number 2.Page l of o3.Emergency Response Phone 4.Manifest Tracking Number" <br /> tltp 371- t� pp f 9 ¢' f + <br /> WASTE 5T47 JJK <br /> MANIFEST ~,� <br /> 5 Generators Name and Mailing Address Generator's Site Address(if different Nan malling address) <br /> 44 I to <br /> GeneralA Phoned** },517 c-) <br /> S.Transpoderl Company Nama mr5 C-r�u�'+%nmt-�sr M- C v'cc-s �� U.S.EPA ID Number( f.jWLj Cj035''5Lp <br /> 7.Trarisporter2 Company Name U.S.EPAIDNumher <br /> B.Designated FecilityNamd and SileAddiessU.S.EPA ID Number CPcDD+{400555(., <br /> r F,I6: c1,P1 P rX.I r."t r= I. .,_iG t i&:+,. <br /> FacjUys Phone:li$_.ip`fSr a7 <br /> -gra ON U.S.DOT Description(including ProperShlpping Name,HazardClaas,IDNurber, 1g. on am I1.1olal `12,UNP. AWaste Cetles <br /> HM and Packing Group If any)) No, - TyPe, Quantl WWol. <br /> 1 fjo" ,tCr2.d f9'ye<t•i.?Dt.., .:Sx`(''„ yi Y(,U -"-Tl All OFt'U@(t7T <br /> t H <br /> 4. j <br /> i <br /> 14 SpeclalHmdlinglnsWellonsardAddieo allnrormagon <br /> y r ��,�.. .. . i K � s� � r•1 <br /> ae'ltrr ft:JFi'rwFr Sr?R':r fr;ell�l '*3e � ~u L sSs.i 6 ti. � 1_.'^1 <br /> }ANDIZE'R TE)J@i TRAIREf.> 1f•.ilii,I'9 P,f>v'i7G`%'r'_O Pile 4 <br /> C.R. COPfiK?;:Y!ir? P,'.f:I.1_: j?er..i,-.,ri'.ny„ hf,ot. Sc'R:1!�F.i•ii <br /> ` `15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and allOmtolyddscnbame;ed show by the propershipping nand am classified,packaged; <br /> marked and labeledrplaczrded,end mein all respects In propercondi-doe forhanspon according to applicable IMemalionaland national gommmenlalregulitlons.lf export shipment and lam the Primary <br /> Exporter,l ceNfy Thal the contents of this consignmanlconform to the terms of the attached EPAAcknowledgmentof Consent. <br /> I partly Oat the waste minimization slalementldenUOed In 49 CFR 26227(a)(d tam a large quantiy generator)or(b)(ifl am a small quardl ygenerator)is true. <br /> - �GeneratorWf(emes Pnntedffyped libund';+, ,,,;f v4.'c;.h'� ,Slgnafure n Month Day Year <br /> I6.IntemaUonal SUlpmedle <br /> F ' Dlmponbl.5, ❑❑xdwe,U.S. Foleren eell: <br /> E Transperlerslgnalure(forexpopsonly): Date leaving U.S.: <br /> W 11.TanspoderAdmowledgmenefReceiplefMaledals <br /> F2 TTnspponer l Pdnled/lyped Name alum Month Day Year <br /> - <br /> a (_..2- f r_ h 4i_ •(r�L:'t': C:4'r , _i pn ri; it : l ,s t £ S t \ <br /> aTransporter2 Pdnledllyped Name - - Signature j \ ”-' Month Day Year <br /> K . <br /> F <br /> 18.Discrepancy <br /> Its,Discrepancy indication Space ❑Ouangly ❑Type El Residue ❑Partial Rejection ❑Full Rejectlon <br /> Manifest Reference Number. <br /> IBb.Allemate Facility(or Generator) - U.S.EPA ID Number <br /> J <br /> to <br /> _LL Fac!liys phone: <br /> W 16c Signalum ol'Allemale Fadlity(or Generator) Month Day Year <br /> !Q ' <br /> 2 <br /> y19.Hazardous Waste Report Management Method Codes(I.e.,codes forhazardous waste matmenq disposal,and recycling systems) <br /> / ../ <br /> 2. 3. 4 <br /> 20.Designated Facility Owner or Operator.Cenficatian of receiptof hazardous materials covered by the manifest except as noted in Item 16a <br /> Pdnte yped Name Slgnakea "ti Monty Day Year <br /> 641 /V <br /> EPA Fen 8780.22(Rev.3-05) Previous editions are obsolete, %' DESIGNATED FACILITY'S COPY <br />