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' J . <br />Please Drmt or two IF.. dnelnned rre nsa nn erne rf�_nunhu,me,.n taxi <br />vnrv,mmw-c<1ney. o -vol rrnnwsamuons are oosDie�. �) DESIGNA'11D FACILITYTO GENERATOR <br />UNIFORM HAZARDOUS 1 1. Generator ID Number <br />M (1/1 !l G� <br />2...Pa2lof <br />3.Emergency Respome Phone 4. <br />-%q.V1WASTE <br />Manifest Tracking Nmb <br />-0 J si Cs 4 JJK <br />5.9efieralo$ Name and MaiingAddress Generator's Site Address Qtdifferent than mailing address) <br />GoneretoesPhone: <br />(I. TragspoM1or 1 Compairy PYame U.SS.l. EPA ID Number <br />i;- <br />I. transporter 2 Company Name ., n U.S. EPA ID Number <br />\� a <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />.:t 11 /'T'ec1 fxI <br />/(:sof( ✓',>'<'1'/[/tit :a !3cf <br />.�4. Ph f. r e. I,. l r' 7 r / ., . <br />Facllll a Phone: i : e rY) 1 1 " /. (/ al. [_y .4 /- �.a 9 f� { /i : 7 <br />go, <br />HM <br />Ub. U.S. DOT Description (hdudi g Proper Shipping Name, Hazard Class, ID Number, <br />and Packing Group Off any)) <br />10. ConlalnOro <br />11. Total <br />Q. Unit <br />13. Waste Codes <br />No. <br />Type <br />Ouantily <br />VAM, <br />INA, '.31127,,-16/7(!f'<llr lunPte >»/f r//7.n,5/ <br />�)vUb196 <br />ko <br />' <br />�l,r'rt:illll(CtFr[,.ilV V' C' <br />Pm <br />aL7J <br />!1� <br />Z <br />W <br />2. <br />3. <br />DEC <br />0 <br />LM <br />4. <br />NVIRO <br />ME <br />TAL <br />EAL <br />~� <br />14. Special Handing Instructions andAMlilkmol lntwmalbn <br />tv <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that flaimnlanls of this consignment are fairy and aycaaloydescmbed above by No proper shipping name, old are dassified, packaged, <br />markod and tohelo llplacoNed, and are in all respects In pmperconci for transport according to spplbable Imemalboxland national governmental regulators. If export shipment and I am the Printery <br />Exporter, I ceNify that the contents of this consgnment conform to the terms of Ute attached EPAAcknmvledgmenl of Consent <br />I cedify ilial Use waste malmhallon statement Identified In 40 CFR 26217(a) Off l am a large quantity generator) or b)QfI am a small quantirygenerator) Is lme. <br />Generam'slOgerors Pdnled7Typed Nome Sfgnalu /' /,�' Mmllh Day Year <br />i � ,1•:: '. �_' %Jl'- l /1 f U '+ � �CJ a !'aZ <br />! �.{:'.! c.,� .�`;, r.,��r'� : ':ds-:,�" �a• %,�•.•'l .� <br />—1 <br />18. International Shipments <br />❑ Import to U.S. Ll Export from U.S. Por).bf eDlryleidt:- <br />- <br />Transporter signature (for exports only): Dale leaving U.S.: <br />w <br />17. Transporter Acknowledgment ofRemipt of Materials <br />a <br />Transporter 1 Panholtryped Name Signature / Mwlh Day Year <br />3escyC'_ i <br />