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Aug 17 10 10:14a Dawn Wickman • 7yr`698-3485 p.2 <br /> Please print or type.(Forel designed for use on elite(l2-Pilch)typawrilK..) Form Approved.OMB No.205O-0039 <br /> UNIFORM HAZARDOUS 1.GenmatorlDNuroef 2.Pagetof 3.Emorgency Rasporae?hone 4.Manifest TracYJng Number <br /> WASTE MANIFEST - 0 lJ 574677�. JJ K <br /> S.GanwaWs Name and killing Address Gereatar s Sge Address'(;l dinamnt than mailing address) <br /> Generators Phone:yr - - <br /> 8.Tmnsponer 1 Companyj N • "- U.S.EPA ID Number <br /> 7.Transporter Z Company Name U.B.EPA ID Number <br /> G21: o 7s- <br /> 8.Designated Fadlby Name and Site Addross U.S.EPA ID Number <br /> cm Re'. tv-1 k5'v< <br /> 1G1 Hagan or <br /> FadityssP�ate: _ <br /> 9b.U S.DOTDesaiption pncWdkg Proper Slipping Name,Haeard Class,ID Ncmber. 1O.Containers 11.Total 12.Unit 15 Waste Qom <br /> HM and Parking Gmup(it any)) No. Type Oua" WWN. <br /> 1. " <br /> 4' ar <br /> i•E:rfr RCE.4t-!�,'_EF.U0US NH.4$iE 'vQUL fw!j aasofren; lagsr 2 J „U.} <br /> o 4W <br /> z 2 <br /> w <br /> ca <br /> 3 o pg��atp'a�EF <br /> 4. rr►�y�gg Fv1 d <br /> 14.speca-Hancing le.shrudionsandAdditionalmokermalion <br /> ERGO 171 <br /> USE GLOVESS <br /> 15. GENERATOR'SIOFFEROR'SCERTTRCATION: l hereby declare that tine conbanLs of tris consignment are fulyand accumtely described above Whe Proper shipping name,and are dasslad,packaged, <br /> marked arc IaboWplearded,and we in all respects N proper condition for transport accordr•.9 to applicable International and national govemmeWA eguie6ora,8 export shipmanl and I am the Primary <br /> Exooder,l certify Thal tte ccnenb of this censignmard conbnn M Ne tenor of Ne attached EPAAtknoWedi of Consert. <br /> I codify t1Wthe wase min'mbabon statement 1dontifred h<0 CFR 26227(a)(J l am a large quantity gematorl or(b)(H l am as mag quantilyg Mr)I0 aneYear. <br /> Generaloest0fli P.nnedrr eE Name S tlure� 7 Mpc¢� DayS--,Q <br /> J 1E.IManamnaimpmems I— <br /> Import to U.S. Exited from U,S. ort WenbyfexiC <br /> E Traropoder signature(for exports only): Date leaving U.S.: <br /> w 17.Transponer&-knoWedgment ofRecelot of Materials Month Day Year <br /> Transponarl redTypedN BigraN:e f� <br /> AMnm gay Year <br /> aW Tran 2Pnnlediami <br /> Signe �•� <br /> � � G <br /> 18.Discrepancy 1 18a.Discrepancy lndkaCoo Space Quantity Ova [I I— <br /> Residue L:Pagel Rsped a ❑Full Relectien <br /> Manifest Rafemnce Number: <br /> 18b.Alternate Faddy for GnenemloU.S.EPAID Number <br /> J <br /> U <br /> FadIINJs Ptmna' IAb th Cay Year <br /> 18c.Bignalum of Alremata Fachly(o•Ganemlor) <br /> Q <br /> Z <br /> 0 19.HemNam Waste Report blana9emen11.7e:fedi Codos(ic.,modes for hazaNarn was:elrealma:lt,disposal,and recycling systems) <br /> 3. 4. <br /> 20,Designated Facility Ow1Nr 0i'Wm ist:Certification of mosipl of hazgdoms materials covered by Lia mantes:except as noted n Nam 18a <br /> PriI— <br /> nied�Typed Name Blyra µerrill Day Year <br /> EPA Form 87ga22(Rev.3-05) iousedtionsareiobsolete. D ,SIGkA EbFACILITYT GENEFL4T F <br /> r <br />