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Please print or type.(Form designed for use on all(12-Pitch)typewriter.) F'ortnApprewd.OMB No.2050-OD39 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 1 3 Emergency Response Phone &Namhet_ NumEv p <br /> WASTE MANIFEST <br /> 224 " <br /> "R ' t'f '„ ^ p <br /> 5.Gensrabh Name and Mailing Address 4.1 <br /> enaratah one Address, mereM Nan reau g s cuss) <br /> GNwaCYc <br /> s .gTy <br /> naBpv <br /> U.S.EPA ID Number <br /> 7.T renewer 2 Company Name <br /> U.S.EPA ID Number <br /> 8.DespWetl Facility Nameand SdeAtldrpa <br /> U.S.EPA ID Number <br /> gy 90.U.S.DOT Descroon(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Patel Group Is any)) No. Type Quantity Wit n3.Wate Codes <br /> e bt sSstsB< t i. ' G. 3xL+ 's vdl' <br /> o > <br /> '-.vK}.vJL^t 6W'Yftlr tsl4 �Cf.AEBSf +• �".�p ..<cAx-.^.,:. � .• '__ <br /> � 7:E^IFi t.w �•Y�Ae'�t :fK�CO'f%: P{ <Sx._,.xis 1r ' _ . <br /> 3. <br /> 4. <br /> 14.Special Handng IUtrucaans and Additional InWmla cn <br /> 15. GENERATOR'SIOFFEROR•e CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and a2 dassideQ packagi <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemah'onal and national governmental regulations.d export shipment and t am rhe Primary <br /> Fxportar,I certify Nat the contens of this consignment conform to Ne arms of the atradred EPA Ackno+dedgmi of Consent. <br /> i ceNfy Nat Ine vrufe minimization statement identified in 40 CFR 262.27(a)(if I am a large quantky generator)or(b)if I am a smell quantity generatnr'I is aria. <br /> d7eraoe&,5%mts PrintedRyped Name &gni Onlav ear <br /> ( t <br /> 16.International Shlpmess <br /> i ❑Import to U.S. ❑Export from U.S. Port of en✓y/exiC <br /> Transporter stratum(for sardine only): Date------ <br /> 17. <br /> art-17.TransponerAcinovledg;l of Receipt of Malerels <br /> Transporter Pirmlix1mythed Name ign2Nre Mpnth Day year <br /> Transporter 2 Pintedirryped Name _ ignatme _ Monty OF FF Year <br /> 18.Discrepancy <br /> 183.Dlsaepancy Indicxtlon Space ❑ Ouec. j� ❑Fun Reject. <br /> bly ❑Type ❑Residue ❑ tial Pel_.lion <br /> Manliest Reference Number. <br /> 18b.Aftensee Facility(or Generator) <br /> U.12AID Number <br /> Ra RI�GE <br /> ru- Fads s Phone: ( <br /> 180.Sign2wh dApemall Facility(or Generator) <br /> Mon Day Ytar i <br /> Z NOVf <br /> N19.Hazardous Waste Report Management Me9ptl Codes f.e.,codes for hazardous waste treatment,disposal,and"ing systems) I <br /> D 4. <br /> ENVIRON HEALTH <br /> 1 20 Daaignated Fai Owner or Operator Certigcsdon of receipt of hazardous materials covered by the maniha except as noted in Item lea <br /> PirfintedifTyped Nine Signature Monty Day Year I <br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. GENERATOR'S NF! 2i U <br />