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Form Approved,OMB No.2050.0039 <br /> Please print or type.(Form designed for use on elite "-pitch) Ater:) q plane t.ManlmaFTmcklnp Num r <br /> 2 <br /> UNIFORM HAZARDOUS 1.Generator ID Number C .page l or ElragencYa 015384194 JJ K <br /> WASTE MANIFEST V - �I <br /> 6.GonondofeName ani MaMrg Ameac Crate 31m Addm sW dMmnnllWn mmnq sddiasi) <br /> 6-CS Ke-r-iIL)1Nf" <br /> AVs. STOOKTOn/ CA_ g5�45 <br /> Garxatdrs Phosu: ✓�''Jr UA EPA 1)Nunwor <br /> 6,Tronalmor l Company HaM �Ip QO,�I ' ri <br /> U °7 9005 <br /> U <br /> U,S.EPA IO Number <br /> V.TmnspaIDr 2 Carrgriny,Nmna <br /> B.DeslgnalaQ Fadelyttamdand Slle AJdreas. U.S,EPAIDNumb6r <br /> 0 014 / 14%Z p/ <br /> Nwy X15, �t M,l s s. OF � r�7 ��"4PA VT �a �o e!p <br /> Facet aPhona: QDo — �� 1 - �C <br /> 10.Containers 13.Waste Codas <br /> ga go.U.S.00T Desalption(indud6g Proper Shipping Name,Hazard Class,lO Number, 11.Total ru <br /> HM and Packing Group(if any)) No. Type Cursory WINS. <br /> NR 3077a 2/�P�Ot � .1�+S7E� <br /> w 2• <br /> 4. <br /> 4.SDectNHwrd6rg nswWonsbntl A0rG6bnellNwmadon +u ��lo.y�� <br /> �MIKEn cku� <br /> � o , Oa3 5 . - old <br /> GENERATOR'SIOFFEROR•3CERTIFICATION:Ihamay deckre Nailha conW-1th.MAMP-MI omlUdyand accurately d",lbed above by eto proper ehlppkrg name,slot are UasslAed,prckaged, <br /> marked and labeledlplacarded,and are in aA respects In proper=0leon la nonspon accaNM9 to applicable International and md.1 not governmaNal regubllens.If export sMpmenl and I am IN Primary <br /> Enporter,I tarty that the contents o11hls caulgnment conform b the nam of the attached EPA Ackroxlodgmenl of Consenl. <br /> I taliiy that the wade mdnlmlmtan statemeWdenWod In CFR 262.27(a)(if l am a brae quantity penamlm)a(a)9l l am a small quantity generaloQ Is M. Mart Day year <br /> ,nonlais/ORe wapdntedRypad Name Sgnalure L, <br /> F 16,International 5 Wants El Import to U.S. ❑Expos wo,US. Pod of enlrylecll: <br /> 'Z— Tr msp�iler olpatum lfw oxpoyk9OM); <br /> DalekaNnBU.S <br /> w pea17.TrasspCrkry . al eNof llx?Iplal Melon* I �"" 2 Year <br /> mn <br /> 1' s rl Riest ni N Nanlu <br /> tom- <br /> ra. huMN Day Year <br /> z Transpode 2PAnkMyped name Slgnabre <br /> } 16.Discrepancy .~.. <br /> 16a.Disasparlry lntlicallgl Space " O.nay ❑Type ❑Residue ❑Partial Rejection ❑FWl Rajadbn <br /> 166.—Ai N;1--17;is FaoTly(arGenamIV) <br /> 2usd <br /> LL f�itya Pln;�: t4pMn Day Yew <br /> w 18c.Slpnalure oiANmala Fad y(or Genaabq <br /> a �'vVi�EnliNdF\Tf LH�9 <br /> on <br /> 19.Hazardous Waste Roped ManaAamnnl Malhod Codas jl.e.,dddes la hazardous Kasle lmalmant,dispd rQ(;}�1�13}'!�,E. <br /> 0 7 <br /> 1 <br /> 20.Des1rawled Faky Owner or Operator:CeNOcaton o0arniptothazasdousmaterials covered byme maNlest xvicept as noted In Item lea hb Oay a' <br /> 1 PrintWyled n 1 y b o <br /> FpAFWM$70D.22(Rev. 'reh us editions are 0ns01e DESIGNATED FACILITY TO DESTINATION STATE IN- REQUIRED) <br />