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71D. <br /> Please�ypa.(f'mslBne/r5tla0 elite(17gdlch)IyPoµ'rilec) Form Approved.OMB No.2050-0039 <br /> UNIFORMHA7ARDOUS 1,Generator 10 Number 2.Pagel of 3.Emm9erlsy Response phone 4,MMant Tracking Number <br /> WASTE MANIFEST 015384424 JJK <br /> 5.Gera2ldsframe and amXutg Addre:a here rs Si!eAdJross ril digc�onl then maNlmJ eddrosa) <br /> Generators phone `Z <br /> 61 Traropalor I Company Name U,S.EPA ID Number <br /> oY✓ SEIZVr C65 /0,00 l3W <br /> 7.Three er2Campany Rame U.S:EPA®Nu er <br /> &40gneted.FaMay Nome and SAOAdNzrs661 7TV U.S.EPA ID Number <br /> EfciW qS <l rkJtJ; S" v 33op looC�O <br /> Facing aPhone; <br /> ga. 9b.U.S.DOT Descripl'imlincJudrig Proper SNpping Name,Hazard Class,ID Number, 10.Containers II.Tolel 12.Unil 13,Waste Codes <br /> NM and Packhg Group if any)) N04 Type Ouantity "Mi. <br /> BOLA DlilF 12 <br /> r$p l ar�61 <br /> Nos 2 E EI V <br /> 3. 0 2 2011 <br /> 4 N -HEALTH <br /> F T7SE ,ACE <br /> 4.Spafint HaMting m89ucaan3 arrdAdJl9onel lnlmmation <br /> I 0� �5�! -I D <br /> 1 . GENERATOWSIOFFEROR'S6ERTIFICATION:(hereby dedmethffithe coolants of this consignment are fully and accurately daecile6d above by the proper shipping name,and are Misfiles,packaged, <br /> marked and labeledlplararded,and are in all respects in pmpercondition for Itanspod according to applicable Inlemaa0naland national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment mnfmm to the terms of the attached EPAAcknoMedgment Of Consent. <br /> I ceAMy that thawasle rridmhaton statement idenlifmd In 40 CFA 262.27(a)(8I am a large recently generale)orto)IMI am a mal glmii9ry genebroo Is mse. <br /> GanerasiN'sATAaa's prinkiffral Name SIWIeIw Month on Year <br /> /ew6w - N E roe <br /> F 15.INemsttonal SNpmeNs ❑Import to U.S. ❑Ekpadfrom U.S. Porlofenlrylexil: .._ <br /> Trampler Signature(far expels DnI,IiJpevtlg U.S.: <br /> w 17.Trasppd rAcknoMedgmenl of Receipt of Maledals <br /> Tram Name Signa a. <br /> orl "iWet appeal Day Yam <br /> G <br /> QTr:rsporle Pdn (vp .am) Sq .lura am Day Year <br /> } 18.Dlscrepenry <br /> 18a.Discrepancy lndkation Space n Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> tab.Allemsie Facility(a Domineer) U.S.EPA ID(dumber <br /> J <br /> U <br /> ra+- Fmorl oPhone: <br /> w trip.Sgrmtma olMternete recall(or Gonaralor) ManN Da/ Year <br /> z <br /> an 19.Hazardous Waste Report Nonallmore Method Codes Is.,codes lm hazardous Waste treatment,efsposal,eM regdOng systems) <br /> 3a z a. 4. <br /> 20,Designated Facility Owner or Operator:CeNgcallon of recept of hazardous matertala covered by the manifest except 45orted in nem tae <br /> lPr eu/ryRedN S�Nro ,`Uv, /, a rN D§y locallocal�/� VI�.1U� <br /> EPA Fonn 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />