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Please print or type.(Farm deli nod for use on elks(12-pjtAt}typewitter.) ForinIApproved.OME No,2050-7039 <br /> UNIFORM HAZARD4Us 1.'Gari ID Number 2.Page 1 o° 3.Emergency Respini Phone 4.ManafostTraching Number p <br /> Gil <br /> WASTE MANIFEST � <br /> �.''' r i`!31,10 F <br /> 5.Genera".ors Name and Matti Address Generator's SifeAddress(d diferent than mailing acrremsl <br /> Generatods Phena <br /> 8.TransDorier 1 Company Nam U S.EPA ID Number <br /> 7,Traisperter 2 Company Name ' H.EPA ID Number <br /> B.Designaled Faculty Norrie and Site Ad*ess U.S.EPA IC Number <br /> 1�acirays Phone: <br /> ga, i U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containere 11.Total 12.Unit <br /> HM and Pacldr@ Group(if ary)1 13.Viaste Codas <br /> No. Typo Quantity 1NtJVDi, <br /> Cr <br /> W <br /> .Z 2. <br /> Uj <br /> RP(iiii'SIVED <br /> 3. <br /> AUG 0 6 2016 <br /> 4 <br /> ENVIRONMENTAL HEALTH ' <br /> 9 <br /> 14.Speaal Handling IrrstrcrcGcns and Addtloral 11in, <br /> - I <br /> 16. GENERATOR'SiOFFEROR'S CERTIFICATIONS 1 hereby declare that the contents of this consignment are fully and accurately descdoed above by 12a proper shipping name,and are classified,packaged, <br /> marked and laWedlplacarded,and are in all respects in proper crrifton fertraysport acoaniing to applicacle international netlatal governmental regulations.trexport shipr i and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms cf the attached EPA Acciohv':edgrtent c`Conse t. <br /> I ser*that the waste n inimizai statement identified in 40 CFR 262.271(it i a-u a large yae:it;,=cer:erL:uri ar(b)(;.`f am a small quantity generator)is tura. <br /> Generalor°r40ferges Priatedi"yped Name Signatu•-- Mon% Day Year <br /> j 16.International Shipments <br /> H ❑import toi ❑E"dfrom U.S. Pad at ani <br /> Z Ttanpo%r atgnanrre(fdr experts onlyi: Cate IeOVIN U.S.'. <br /> CC 17.Transporter.WcfvhawledgmeMof Receipt Df Matadals <br /> Transporter 1 Printedffylow Name Signature monk ReY YM <br /> Transporbi FrirrtedTyped Name S'gnah:re Month Day Year <br /> ?a.D saepazcy lndicatlor Space ❑ Ouartllly ❑ ❑Residue Paliat Rejection I_Puff R)edbr <br /> IAanifes:Reference Nrmbe' <br /> `Bb,Altamaha FaciGty'cr Genera-,or) U.S.EPA ID Number <br /> J <br /> V <br /> u- Facli:y's Phone: <br /> M IBe.SignartireofAitem9teFall(or Generalor) FAar>Ih Day "ear <br /> IR <br /> Q <br /> a <br /> y19.'riazardcus Waste Report Managerrerd Method Codes(i.e.,codas for hazardous waste treatment,disposal,and recycling systems) <br /> o L 2 3. 4. <br /> 20.Designated Facfity Owner or Operator.Certl!`.catiar of receipt of hazardous naterals wavered by the manilest ezcupt as rhrted ire item 18a <br /> Fnntea/Typed Name Signature Vcnth Day Yea- <br /> EPA Form 870>3-22(Rev.3-05) Previous editons are obsolete. <br /> GENERATOR'S INITIAL COPY <br />