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*"4SC . u '3 ? 194 - 0943 t <br /> Please print or type.(Form designed forum on elite(12-pitch)typewriter.) <br /> form Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page i of 3.Emegenry Response Phone 4.Mandate Tracking Number <br /> WASTE MANIFEST � /Q 7 pt� JJK <br /> S. ratys„miend�aifng Address `t4G Genera sSbe Address(il tliRereni than mailug address) <br /> 1aN7 MclaUt LO&Y - <br /> GeneratofS <br /> 6.Transporter I Compatm/ ame U.S.EPA ID Number <br /> /r8d1/&(e 1&1 _Szrlfde�eS Q o'Zg <br /> 7.Tran er 2 Company Name U.S.EPAIDNumber <br /> EK� W Cul ✓C' i �.Q IC CII a U� <br /> II ahtyaa Facility ame and S�'1e Add ss U.S.EPA IO Number <br /> pD to Q�GVe✓fora <br /> L47ti� F C 9gD8((3j 't <br /> FaCidy'shone: "s�.f.�r7"ru77 - b '1040 <br /> ge 9b.U.S.DOT Description[including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12,Unit <br /> HM andParlarg Group(if any)) 13.Waste Codes <br /> No. Type Ouanery, WINoI. <br /> ffi ' Vou- QCra LuoS s- ct <br /> b K 100 P 335: <br /> Z Z. <br /> W <br /> 47 <br /> 3. <br /> 4. a■n <br /> t,.s IHaMIi9.1Inst01jtp✓fswr(Iniesel G + 1f �Y� mom- S75fj <br /> n�5�3 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by to proper shipping name,and are classified,packaged, <br /> maAed and labeled/placarded,and are in all respeds in proper condition for banspod accoroing to applicable intemabonaland national governmental regulations.If export shipment and 1 am the Primary <br /> Exporter,I certBy that the contents of this consignment conlorm to the lams of the attached EPAArdulna/edgmenl of Consent. <br /> I certify hal the waste minimization statement idernified in 40 CFR 262.27(s)(t I am a large quantity generator)or(b)III am a small quantify geneator)is true. <br /> GenerabfsrOfferoes PrimedRyped Name Signa Monlh Day Year <br /> 01F 76.International Ship is 11 Import to U.S. ❑Export mom U.S. Pont of entryle at <br /> Transporter sgnamre(for exports only): Date leaving U.S.: <br /> K 17.TramporlerAclanovvedgmem of Receipt of Materials <br /> Transporter l PrintedRyped Name Signature Month Day Year <br /> airJury 102A.23 10 <br /> Zra 1 rinUtIfTyped Name Si ,atu Montt Day Year <br /> Q l.�''lti U . I 1.)-q U,� <br /> i18.Discrepancy <br /> 78a.Discrepancy Indication Spa® Elpuantlry ❑Type ❑Residue ❑PaNal Rejection ❑Fill Relxton <br /> Manifest Reference Number <br /> 18b.ARemets Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> Facility's Phare: <br /> w 18c.Sgnalue of Aeemate FaaGry(or Generator) - Month Day Year <br /> a <br /> Z <br /> r, 19.Hazardous Waste Report Management Method Codes(ie..codes for hazardous waste treatment,disposal.and recycling systems) <br /> Sala 1. ' 2. <br /> 20.Designated�Ry Omer or Operator, nicest Certification of rept of hazardous materials covered by the manifest except as nded in Item Ias <br /> 1 eNfyped Name Signa Month Day Year <br /> V-nnt0.\)YG DJQ 02 12 to 105k <br /> EPA Form 5700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REOUIRED) <br /> 10510.0967 <br />