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Please print or type. (Form designed for use on elite 112-vitchl .) <br />From Annmvfld- OMB Nn 20Vrl./Nl'19 <br />iii <br />UNIFORM HAL4RDOU5 <br />",Generator 10 Number <br />2. Pe i of . Em xyReswnse Phone <br />4. fV�ffVI Nu <br />I <br />WASTE MAN <br />s„ <br />I <br />05401 JJ K <br />5 Generator's Name and Malting Address Generators Site Address (d ditfererit Ulan ma09 address) <br />J R7 I' ft+ 41..E <br />11-0 i is MAIN ,:; T t t � � � 1ookill "_ i <br />Generators Phone �l f; ; , N Mg, �+ <br />6. Transporter 1 ConVarry, Name V.S. EPA ID Numtber <br />R`ditlftY'FI`,01'1E,�Wff4IA,) "I MfIt. W f` A Cr 11 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8 Designated Facility Name and Site Address U S. EPA ID Number <br />RAh,l')f:IlAt <br />1515 C1,01! ; F14 (AIVPR tc117S0t, f <br />Wr-1 T r'11f.€ AtVi"NCt:x .A IrkAI <br />+_ A it 0 4 4 1) 0 3 5 ,. h <br />FadLysPhone: i1611A 4e <br />ga. <br />9b. U S. DOT Desaiption,(Inctuding Proper Shipping Name, Hazard Masa, ID Number, <br />10. Containers <br />11. Total <br />12, Uftti <br />t3. Waste Codes <br />Na <br />Type <br />HM <br />and Packing Group (if anyjj <br />Wardffy <br />+tyLW. <br />Iai ,f4 Ia; IY,~, [JA 'AI;Crk )lfi►, ;I t;1,,I >:ti ?k:4t f WA f(?1 <br />I <br />! <br />Li <br />r <br />u,1 <br />2 <br />2. <br />w <br />C7 <br />3. <br />4. <br />special Handllno Instiuctons and Additional Inforrnavon <br />it" 4 LAI t ;'A + , i .f r + i F 1i th}£_ 'AFPfk44dA1k PEASMAL PRi}[t .t`TiVE <br />��'7t slist� tJ C <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that ft contemts of this consignment aro fully and accurately descnned some by the proper shipping creme, and are Wssilied, packaged, <br />marked and labe+.edlplacerded, and are in off respw!s in proper condition for transport ung to applicable intemalk=1 and national governmental regrs'atiarw. It export shipment and I am the Primary <br />Exporter. I certify that the contents of this consignment conform to the terms of the elWrhed EPAAcknowdedgment of Consent <br />I certify that the waste minanization statement identified In 44 CFR 262.21(a) (d 1 am a targe quantity generator) or (b) (if I am a small quantity generator) is (rue. <br />Generalorsloffews Pnrrledlfyµed Name Signature Month Day Year <br />A <br />..J <br />16. Intemational Stipmenls <br />❑ Import to U.S. ❑ F_xpod from U S Port of enfrylexk: <br />Transporter srgrtafure (fix exports onty): Date leaving U.S <br />17 Transporter Admowiedgmenl of Receipt of Materials <br />Transporter 1 KriledlTyped Name Signature Month Day Year <br />O <br />a <br />QTransporter <br />2 PrinledlTyped Name Signahrre Month Day yew <br />tY <br />r- <br />18. Mcirepancy <br />rr � ' t <br />18a. Discrepancy Indication Space ❑ rguamit � Typ ❑ Residue l_I Partial Rejection LJ Full Rejection <br />Manfesl Reference Number. <br />I9b. Altemale Facility (or Generator) U.S. EPA ID Number <br />U <br />Fadik js Plane: <br />W <br />F@— <br />18c. Sgnature of Alternate Facility (or Generator) <br />Month Day Year <br />Z <br />. <br />'tazardous Waste Repo" Management Method Codes (i.e_ codes for hazardam waste hsabranl, disposal, and racyd ing systems) <br />2. <br />3. <br />4 <br />21. Designated Fadlily Owner or Operator Codification of rea fpi of hazardous mtater{ds covered by the mangest exwpt as noted in hem 18a <br />Printagyped NArno Sigrghrra Month Day Year <br />EPA form 8700-22 (Rev. 3.05) Previous editions are obsolate. GENERATOR'S INMAL COPY <br />