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Please print or type. on designed fa use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.P I of 3.Emergency Res Form Approved.OMB No.2050-0039 <br /> age rg mcY ponce/Phone 4.Manifest Trackln Number <br /> WASTE MANIFEST �. i�=Qp 3 z 4k'f5 -73.8 7G3 G B F <br /> 5.Generators Name and Mailing Address Generemrs Sim Address(t arrawnt man having address) <br /> /}lrl�y(lCAn) lAf&£% L✓rfSTL` . <br /> �1 I�Po43a� <br /> Gereremrc Phoma: r Z' T LEL I <br /> 6.Transporter 1 Company Name U.S.EPA ID Nu 7 <br /> -1171C,IG1- 17„� r/ GGt D/L <br /> 7.Transporter 2 Company Name U.S.EPA ID Numb <br /> B.Designated Facility Name and Site Address <br /> L) <—l /�(Q U.S.EPA ID Number APR 24 2 <br /> 308 G/{e✓/2 9,)4JA <br /> '�0-6g3_�og D Ko,,l cq. q�6zts ENVIRONMENT L <br /> Fatlay's Phare: — /9' H FA'.TW nrzoa RTJ sCH <br /> 9a. go.US.DOTDesaiption(including Proper Shipping Name,Hazard Cross,ID Number, 10.Contaimm It.Total 12.Und <br /> HM and Packing Gmup(t any)) No. Typo Quantity wl nmI 13.Waste Codes <br /> o <br /> i Z <br /> i <br /> 3. i <br /> 1 1 <br /> If Special Handling mstmcbons and Additional Information <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that t*contents of this consignment are fully and accurately described above by the proper shipping name,and are Gasslfied,packaged, <br /> marked and labeledlplaorded,and are in all respects in proper condition for transport according to applkaMe inmmational and national governmental regulations.It export shipment and I am the Puri <br /> Exporter.I cedAy mal the contents of this consignment conform to the terms of One attached EPAAcknoxmdgment of Corusent <br /> I carli(y that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generates)or(b)(HI am a small quantity generator)is nue. <br /> Gane d I's p`r a Signature j Month Daly Year <br /> J 16.IntemataW Shipments 3 �..5 <br /> Import m U.S. ❑Export Fran LLS. Port of amry/exit <br /> Transporter signature(ter exports only): Date leaving U.S.: <br /> W 17.TrarepormrAcknaNedgment of Raceipi of Materials <br /> Trans r yped SignahaeMonte Day Year <br /> g f� <br /> Transporter 2 Printed Iyped vanx, Bi nature <br /> eMonthDay Year <br /> K <br /> 16.Discrepancy <br /> Ida.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Mantest Relereme Number: <br /> tBb.Nmmam Fecilily(a Generator) U.S.EPA ID Number <br /> J <br /> U <br /> rat. Facility's Phare: <br /> aI.519'a im,un.ternaw Fatally(or Generamr) <br /> - Month Day Year <br /> y'2 19.Hazardous <br /> Waste Repoxi Management Method Codes(i.e..codes for hazardous waste treatment,dismal,and recycling systems) <br /> 1 o 1 I 1 <br /> 2, 3 <br /> 4. <br /> 1 20.Desgnmd Fad y Owner a Opel ..CerHmtlon of re eJpt of hazardous materials covered by the mentestax pt as ncted in Item ita <br /> Pmkd? Nemo - Signe Month Day Year <br /> EPA Form 00.22(Ray.3-05) Previous d'gns ane obsolete. <br /> TRANSPORTER'S COPY <br />