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Please print or type.(Font deskpied far use on elite(42-plich)Itripteviell Form App".OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number 2.Rago,d 3 oncy Rwpmso Phoria 4.MnmfostInacking Number <br /> WASTE MANIFEST RLoo�t. 5n P 77 -�;z 015384435 JJK <br /> 6.Gomrapes Name oM MaRng Address ,.vasa%saa,hldin,(If drylermd Nen Moslem addresa7 <br /> G�S P F-(n){iV 'l_L G 2 Ave, <br /> 51fjc) ►Rlt <br /> ca„mala�sahene: �- q Z7 —F 0 <br /> 6,lmnsp(Yar l Cmihaany Nam'. IJs.EPAtONNnber <br /> (4NT> J C> C�(Z � `ZS4— <br /> 7.Transparboi2Orm irry Name U.SEPAIDNumber <br /> C.Da9Sprokd senld'/Naiad amt Slit Addmas usEPA N)Numbw <br /> (A.5 mac eery <br /> ItwYC161 <br /> FeoNya Plimla' <br /> go, 9b.U.S.DOT Description(including properSNppblg Name,Hazed Gass,ID Number, 10.Come are 11Jolel 12.Unit 13.Waste Codes <br /> HM and Pacing Getup if wry)) No. Type Ouen9ly, WLNd. <br /> � �7, tfw�+3�ocxAS wsZ�( Svc (D, fxl..l <br /> X N, ©-S <br /> Z 2. <br /> 1 <br /> 3. <br /> A, <br /> 1 <br /> 1 Spode H..4rxg lnabuceemind Willonal lnMmubun <br /> gtALKerI G"Uc:T 7 <br /> o c2 ( 5q3 - <br /> 15. GENERATOR'SrOFFEROWS CERTIFICYION:I hereby declare BW we contents of this consignment arefuky and accomest,descrihed above by the proper shipping most,aM are classified,packaged, <br /> marked and labaledblacsrded,and are in all respects in proper condition for transport sanding to applicable hlernalbnaland national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I cedily Nat the conforms of this conslpnmonl contorm to the terms or the attached EPAAcenewiadgmanl of Consom. <br /> I cedRy that the waste minimization statement Identified In 40 CFR My!2ill(111 am a large quanyly generator)or emasmall Auint” gonerala)hfine. <br /> Genemi.eaJ011amys P(inlcturipmJ Name 'S.gon Ment, [toy tau <br /> 2 Go�ctzTc ?4a)(vCz- Iz5 Lb <br /> F I,.Vdenm9gnl shipmcr9s ElImpodlo U.s. I—I Export from U.S. Poddentryfexll <br /> Trenspaiafsgiiahtrr.horpxpnds onlyJ: Dale W419 U.S.: <br /> V.TrampoderAckrmhledgmenl of Recalpl of Netodals <br /> Trans r I rhmrvr Nama Signatures M. Uxy Year <br /> Z (ranspr.�lor2PmilodRylnd rLinln Slgarne" MmN Day Year <br /> K <br /> t, <br /> IS Discrepancy <br /> 1Ba.Discrepancy Indication Space E]Ouanityu I a{L�-j ❑paNal ReJedlon ❑Full Rejection <br /> II$�� �adlf101wiinNkr. <br /> im,Alienate Facility(or Generator) MAY <br /> nfy US.EPA Ht Nn,bs, <br /> 4' A 0 L 20v <br /> FaeOity;Phone: <br /> W Iec'.SynaWm Ed I—Fac"'tar Go"em:«I )Vll�.f � ( NmN Day Year <br /> Flr^ n <br /> y19.1 Inrudan Waste Report Nlanagemed Method Codes(io-codes for hazardous waste treatment,disposal,and fe*04 sy;Mm;) <br /> our <br /> 20Aesignaled FxYi y Oxnera Opemim;CeNfcallon o/remiptof Imzardous materials covered by Ne manliest exapl ae nded h Nem 16a <br /> Illi dcdR a Sgna4lm kionN aY Y¢tr. <br /> EPA Fnlm A71J0'L'2((w,3-05) f§evious edihpns are obsokle. OESIGMATFD FACILITY TO OES71hl ATIOhI STAT• (IF R Ei0l11RED) <br />