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prim rp type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.205HO39 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manffaat Tracking Number <br /> WASTE MANIFEST s 1 - 0 0 7 4 3 6 2 8 FLE <br /> 15.Generators Name and Meiling sperms ? rGC ..rerators,Site Address(it different men minting address) <br /> Ii rl -'fir 3r. <br /> $TOC+R/As/-d s <br /> 4.04 <br /> Generators Phone: 4 <br /> ransporar ompany Name US.EPA ID Number <br /> tFIll P c PLAD K <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> f7 z-S Ll Z.Z <br /> a. signaled Facigty Name artl Slta Address �V/'✓' , LLL U.S.EPA ID Number <br /> Facifil Is Phone:lrt-z '— 3" Sezir l42 2 Ot--O fir-4 <br /> ga, 9b.US.DOT Des::rm on(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11 Total 12 Unll 13,Waste Codes <br /> HM and Pacing Group(if any)) No. Type Quantity 'WBOI. <br /> 1- uDNtP F}a4ZV�?i0t�J5 r..aJN"AZ, r I'JS <br /> ar��(,ww.r+sc �p �tz�are. e�rs�.-r) � br►� �Z1 � <br /> 2v �a Efkrc�t +t]is wws�Ei �r1� 1 <br /> ' L csrfro Vill L4rc2✓rJ ) <br /> 3.Nof� rua$4 yyvzAal�x�vs ,,i�rsr'� , � 3 bF t 3L p 3� <br /> pzw, sero s <br /> 4. <br /> 14,Special 1181 Insln Adore and Additional Infgrmsoon <br /> �) L� ays <br /> li 1 — Gil C 1115srsr� � q�deb —(3K vs <br /> y L-4& 603—GVZ()%�&`i <br /> 15. GENERATOR'StOFFEROR'S CERTIFICATION: I hereby dedare mM the contents M iris consignment are fully and accurately described at by me proper shipping name,and are dassfied,packaged, <br /> marked and laoelecilplawrded,and are in all respects in proper condition for transport according to applicable inearmsmal and rational governmental reguabons If expod shipment and I am me Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknpwledgment of Consent. <br /> I certify that the waste minimization statement identified in 46 CFR 262.27m) if I am a large quantity generatorl or(b)(d I am a small quantity generator)is trus. <br /> Gonerator'siOdspry�ia Pnnletl yped Name stim urm Monthay ear <br /> Yt Z� t( I Q3114- <br /> 16.international Shipments <br /> ❑Import to U 5 El Export from US. Portof erirylexif. -_ <br /> Transporter signature for exparrs only): Date lwa,ng U.S.. <br /> 17.Transporter Acknowledgrnerx ofReceipt Of Mail <br /> transporter 7 PnntedfTyped Name gnaWreonlh 5aay Year <br /> If <br /> are <br /> Transporter 2 Pni y d Name Signmust, Year <br /> E to <br /> ie.Discrepancy ��II <br /> Itis.Discrepancy IrtliCalion Space ❑ Quantity TY, N���ov,I Po ® ❑Fuo Relectim <br /> aY4sn <br /> MSEE <br /> '�18b.Alternate Facility(or Generator) ..r U.S.EPA ID Number <br /> DEC 15 2017 <br /> acibl's Phune: - <br /> lc.Signature ofARemarm Fecal(Or Generator; Month Day Year <br /> ENVIRONMENTAL HEALTH <br /> Hazardous Wa Report Manag rat Method Codes(i.e..codes for hazardous waste vestment,disposal,and mcyding systems) <br /> A \ 2. 3. d. <br /> 7.Designated Facility a Operator:Certification of 'Iof hazardous mMedMS covorad 1:14ho mandest exoept as rated in Item'so <br /> intedlT)peO Name - _ ^ �- 5gnature Month Day Year <br /> WyY� <br /> on 8700-22(Rev.3-1 Previous editionsare obsolete. ^, DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />