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Please print or type. Formdesigrod for use on elite 12- itch)typewriter. �]FFoorrmA proved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number p�,^ 2.Paga 1 W Enver icy Response Phone O 9 Metal f J g 4 4 9 JJ K <br /> WASTE MANIFEST Q Z LZ✓� r �I 1 <br /> S.Genial Name and Melling Address neralor a Site Address(if different than trading address) <br /> lg"�PV'5 G0165 pm-ji INCr <br /> S 10 fit?- RIE. STOC�Too) e14, g5215- <br /> enerafofsPhone: �-t7 <br /> G rmponer 1 e Na U.S.EPA ID Number <br /> .27N *7 13 2-1- <br /> 7. <br /> .Transporter 2 Company No U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> US GcOGO" IvEvw o A NEv r4D A <br /> VW y a5, U M I LES S . o r- C3F19TT'�r 6a4- )Fr <br /> Faclll 's Phone: INIM--12-3q- '7� 1 M v Cl o 000 <br /> tie 9b.U.S.DOTDescdptlon(including Proper Shipping Name,Hazard Class,ID Number, 10.Coroners 11.7.1.1 12,Unit <br /> 13.Waste Codes <br /> HM and Packing Group(Rany)) No. Type Quantity WtNal. <br /> g 1 Al Z 1 Rip-4 u5 w 14,5-re , C� 4JI173 p _"MI <br /> . <br /> 2. <br /> o. <br /> W <br /> E <br /> 3. <br /> 4. <br /> 14;SpedaalHandling 6CyWan <br /> C� st.—'(,,`,./,+ <br /> ltrcdlonee prtdltl° yF}i <br /> AA;,l� &01 Z l a�r�'—`e'er PErWITv[r!1`-E.ai <br /> /7 IFx,�- 'En.)- O O( ?fib 3O3 - 3(o O <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by gas proper shipping name,and we classified,packaged, <br /> marked and labeiedlPlacarded,and are In all respects in proper condition fortransport according to applicable International and national governmental regulations.If export shipment and l am the Primary <br /> Exporter,I cerfiy that the contents of this consignment conform to the lens of the attached EPA Acknowledgment of Consent. <br /> I certify the(the waste minimizatlon statement identified In 40 CFR 262.27(e)(if I am a large quantity gemealar)or(b If I am a small quardy generator)is We. <br /> GenarintarONarm's Printedlfyped Name Signature North Day Year <br /> �A0 t - k'Li 2a 15 <br /> 16.triterna full Shipments — <br /> Export from U.S. Pod of try/extt: <br /> F ❑Impart b U.S. <br /> = Transporter signature(for exports only): Date leaving U.S.: <br /> W ,17.Transporter Acknowledgment of Receipt of Materials <br /> irarreponer Pn `T / ` Si Month Day31 Year <br /> a V N do 110 <br /> kJ <br /> QTransportto yy ame Signature Moral Day Year <br /> F <br /> 16.Discrepancy <br /> the.Discrepancy Indication Space ® Quantity ❑Type El Residue Dental Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 16h.Altemafe Facility(or Generator) U.S.EPA ID Number <br /> U <br /> sa+. Facility's Phone: <br /> W BG. laemate Ity of eaare Of chin Day Year <br /> Ignare o aLl <br /> a <br /> z <br /> U-, 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatmem,disposal,and rocycling systems) <br /> G 1. 2. 0. 4. <br /> 120 Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted In Item 10a <br /> Prime yped e nn� yv nn ignature nth ey "'a"1 I T �'C <br /> EPA Form 8700-22(Rev. 5) Previous edillonsareobaolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />