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Please print cr type.(FoNn d ped for use on elite 12mplkh) evallat.) Form Appruyed,UPAR Nq 2050.0039 <br /> UNIFORM HAZARDOUS i-Genmmlor lD Number 2,Page l of 3,Emergency Raspense Phone 4.Manifest Tracing umber <br /> WASTE MANIFEST cv-�y�cx�o IbS5 � ) CZG4>}�v-sour1 015384484 JJK <br /> 5.Gomerakl/e Nmlw and M.6mg Address'iy;J' r .11 Gene2ble Nis Addrd M(0 0 Karen I Ulan carding ad dross) <br /> 5--HS SNE YFj WOKD <br /> .n bSINU✓1fle UE�102� 64 Ci,4 M�ephmw1// o� <br /> q <br /> 6eLdpd,l Company Name <br /> U.S.EPA ID Number <br /> v5T aNn SC)NS CAwol.6— q,):L <br /> 7,Tmr,spmlor 2 Canpzny,Name U.S.EPA ID Nninhr <br /> 0.Designated Finally Nomn and Site Address U.S.EPAID Number <br /> 1,l,S Cec�L,oe-ay N�v✓tpw �;t�T-n/ <br /> Hwy u5'y it Mi.L6S .5. of �EwT"�yr tvEJ✓� +`t ��O°3 <br /> Fact! 'c Phone: o q y. y <br /> 9m, 9b,US,OOT Desaypliun(including Proper Stupp4g Namo,Hazard Class,ID Number, 1U.Containers 11,Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity WINol 13.Was(.Codes <br /> ( esciv) t C F 3 t Q <br /> w <br /> 4. <br /> 14.$podcl IlZiling lnNn¢Ibnsand Additional Information 'PaoF�� o�oz�+5a3- l <br /> r#3852 <br /> 16� GENERATOR'SIOFFEROR'S CERTIFICATION!I hereby coders that the contents of this consignment are lolly and arnmalely described arcus by the proper shipping name,and are classified,packaged, <br /> marked and Ia6.Iagplacarded,and are in alrp�pests In prupar condillar for transport according to applicable international and national gwernmenlal iegularkins.It expertshipmoM and l am the Primer, <br /> Exporter,I"rlily that the Nnlenls at this conslgrvmeM conform to the lames of the attached EPA Acknowledgment of Consent <br /> I earthy that the waste minimization statement Identified in 40 CFR 262.27(a)(if I am a large Wantiry genealur)or(b)(if I am a small quantity gernrxlor)Is true, <br /> Gommnnet 'sWerars PPdn�lsxUTypo 5 . I. ♦AonW Lay Yea, <br /> 1Q r a <br /> I6.Inbrmahmal Shipments (1��77 <br /> {— <br /> 11 Import to U'S. Ll F.xpod from U.S. Podcfemrylouil: . <br /> Transporter signature(to,experts only): c. Oat.leaving U.S,: <br /> Liu; 17.Transpowr Acknwdeegmenl of Receipt of Materials <br /> - Tr ns rl Prinle ypedN ���� Signature[n If d6ei IAm&I D Yam <br /> O <br /> 6 <br /> 2 Tr Tmd Prud yD.d Na:nc Signature Month Day Year <br /> G <br /> K <br /> f <br /> 1 16 Discrepancyo�m. <br /> 16a.Discrepancy Hddwlion SD.ce Ouanti I� <br /> ty ❑PJN.iI Rcjedwn Bull Rejadbn <br /> MethodistRelmMW Nu <br /> Z 16b.Amc:: .::Fadi ler Generator) aMA 2 s U.S,EPA IO Nvmkr <br /> J <br /> LL Fd..IINS Fhurla: E"t(V ONM.EWALP r✓- H <br /> w <br /> It,Signal n 0 olAhmw!a FToldY lar GeremmQ P;.i �",^( c^ Abort, Oay Yem <br /> a <br /> z <br /> H <br /> 19.Hazardous Waste Report Management Method Cases(i.e.,codes for tazardooe waste treatment,disposal,and recycling systems) <br /> 20.Designer it Faalay Owner a Operator Certification of re"lat of hazardous materials cwered by The manifest except as novel to Item 16a <br /> Pdnlc d '..��{�--/I lure Month Day Year <br /> ` V✓ O <br /> EPA Forma 22( ev,21-OS) Previous editions are obsobte. UESIGNATFD FACILI $t)ESfTFxnm STATE(IF REQUIRED) <br />