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Ploaso pdnt or type. (Form designed for u3e on elite (12•pitcl ;writer.) <br />Form Approved. OMB No 2450.00.39 <br />r <br />UNIFORM HAZARDOUS <br />1 Generator M Number <br />t" +a 1, tj 0 !� 0 1 t1 '3 .17 <br />2 Page i of <br />3. Emergency Response Phone <br />t(;�) 4"4.% 341i� <br />4 Manifest Tracking Number <br />K <br />WASTE MANIFEST <br />t;� <br />a o a s �� <br />I5 <br />Generalui s Norm and Malim AW esu Generatcr'5 Site Address (If d1lerant than maiLng uddress) <br />AFTY LWE <br />MON W cT 1IAjNWIN ST <br />WNMCA GA "'4'vo1 MIA E CA CA S <br />Generator's Phoria cel iii` <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />A tY OlViF{i VENTAi 'TRVICU' C A D 0 2 B e 7 7 0 3 C <br />7 Transporter 2 Company Name U.S. EPA ID Number <br />8 Des-gnated Facility Name and Site Address U.S EPA ID Nunt-m <br />RAWS 1 4MR(N+iNUVAI <br />i!'etff FOUTH R. I VE R RUM <br />11,t l €ACRAllr NTUCA 136t)I t: A 0 0 4 4 0 0 3 5 5 n <br />Faciltys Phone O WN 1 �i/ 1 41y <br />ga <br />9b. U.S. DOT Descnptian (+ndudrg Proper Shipping Name, Hazard Class, ID Numw, <br />10. Cordalners <br />11 Total <br />12 Unit <br />13 Waste Codes <br />No. <br />Typa <br />HM <br />and Pacing Group bf any)) <br />Guantily <br />wivol. <br />ae <br />f. <br />NMRGRA liAZME)OUS WASTE, (011 Y WATER) <br />TT <br />CS <br />001 <br />x <br />2. <br />3. <br />4 <br />4. Spon: al Handling Instructions and Addhonal Information <br />WR0# qh 171 `PROHLE #M `NPPROF-RlAf PER'c�0 Lfk( VP()TrOTIVC EWPNE?tr <br />15, GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby dedam that the contents of this mrtstgn ment are fully and accurately described above by the proper stfppmg name, and are dasseed, pe iuvad. <br />marked and labeledlplacarded, and are in all respects in proper condition for trer%orl according to appilcabie krtentatbnal and national governmerilak regrta`ans. It export s4merd and i am the Primary <br />Exporter, I ce" that the contents of this cons gement conform to the temts of the attadred EPAAdmowledgmerd of Consent - <br />I certify tfat ft waste mnrnzaban statement identified in 40 CFR 262 27(e) (d I are a large quarrGty generator) or (b) fit I am a smah quentiy genarWor) is true. <br />Generdla'slOftenr s PYmtedrTypad Naura Styria ere MoWM Day Year <br />-JIt. <br />(` <br />1%ernatval SnW.vitstf��t1 <br />Lt Import to U.S U Export from U.S Port of entrytexit <br />? <br />Transporter signature (for exports only). Date leaving U.S._ <br />W <br />11 TransporterAchavledgmnent of Hese pt of Materials <br />Month Da Year <br />Transp 1 'ntecVTyyed Signetu r Y <br />"/F.Z <br />, 1;j11101, A <br />aTrarlspo <br />ed1T dAernal Month Day Yes' <br />Discrepancy ` <br />T18. <br />18a. Discrepancy Indication Spece ouantity ❑ Type ❑ Residue ❑ ParlieFRejection ❑ Fug Rgectli <br />IManifest <br />Reference Number <br />eme a Fachly JOF Gener2lorl v s. EPA JU Number <br />U. <br />Fachgy's Phone' <br />0 <br />10c Signature ofAllemate Faddy (or Generator} nth Day Year <br />d <br />— <br />19 Hamrdous Waste Reped Management Method Codes (1.e., codes ter hazardous waste treatment. disposal, and recycling systems) <br />2. <br />3. <br />20. Designated Faolity Dwrier or Operator Certification of receipt of hazardous matadas covered by the manfesl except as noted in Item 18a <br />Pdn'.edfTyped Nana Signature ii Month 7Y9a, <br />EPA Forint 8700.22 (Rev. 3-05) Prevms editions are obsolete. GENERATOR'S 041T1AL COPY <br />