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I - -;11; ---------- <br /> if -'iJ4 - .11 <br /> -PI print or type,(Form desi reed <br /> for use onelite(12-pitch)typewoter) t <br /> S 1. eneratorlDhlum r <br /> UNIFORM HAZARDOUS Fo .OMB No.2050-C <br /> E MANIFEST 2.1`119,11of 3.Emergency Response Phone 4.Me 11631 Tracking umber <br /> S.Gemini Name and 1 • O i� 61 <br /> Generators SiteAddress(ifidifferent n mailing address) — DAT <br /> Generalcry Phone: "ll I'llf" <br /> 6.Transporter I Company No <br /> U.S.EPA ID Number <br /> 7.Transporter Company Name i li.;Af,�Illtll 0 J r rl i, <br /> r IV Number <br /> 8.Designated Falli Name and Site Access <br /> " <br /> t <br /> I�Q';It US.EPA Number- ------ <br /> 4—i - <br /> Facdr a Phone:. Ok, <br /> 9a.. T Description(including Proper Shipping Name Hazard Clan. <br /> HM a Packing Gra (itany)) 10 Number, 44 <br /> 10 Containers 1.Total <br /> 1. 1 2!Unit <br /> No. 13.Waste Codes <br /> iy Type Lnfity Wt.NOI <br /> 2. 311 <br /> 3. <br /> 4. <br /> 14 Special Harling Instructions and AtltlitWnal Infarmalion <br /> 15 GENERATOR'S/OFFEROR'SCERTIFICAIIO <br /> marked and l8beledIPfaurded,and am in alI (hereby ticuint Trial Ing contents of this consignment are fully and.,car <br /> ately tlescdhed Exporter,f the that the contents of this consignment pects In proper 'likinforman naccorcung(Oapplical 1 NOPK shipping name and are <br /> I Consy that the ,,is minimization,statement con 10 the terms Of the attached EPAAcul,Oxiiied laintematichal dnabona(goyemmentalregulstiom.f assiked,packaged <br /> flerneralI nuti in 4 CFR 262.27(a)IN I am a large quantity general gmentafCon, r, f exPON shipment and I am the Primary <br /> S Printed/Typed Name pooI ]small quantly generator)is true. <br /> X <•'X",, � ��hature <br /> F� 16 "WIN8110111)Shipments month UPI Year <br /> Transporter signes, L-J import to UIS, 2 of <br /> Is(for exports prop: LJ Export man,U.S. PON imul I <br /> 9!K 17 Transporter k '1111,1 , - <br /> e wi, Materials -Date Joaving <br /> or Transporter I PnntWypd Na a <br /> 0 <br /> Signatu <br /> Tf=W"r2Pnn (11TYPedName f ?"I Month Day Year <br /> w Signator Z. i I III <br /> .7 Month Day year <br /> Residue <br /> 188-Discrepancy indication Spa. El apeauty OTYP. ❑ <br /> 9 1 <br /> 1' 11 ED Partial Rejection Elul Reflection <br /> 186Alternate Facility for Can <br /> Manifest Reference Num <br /> 75jt C610 Off' "-J <br /> LL Facility's Phone has the 0�f"&e, f <br /> 18c Signature IfAltemato F. al for, and ill acre(., r3ste <br /> this 9eIII M <br /> 65 19,Hazardpas Waste Reportnth Day year <br /> Managen, q, I CIIII <br /> It.a codes bl hazardous waste Treatment,disposal, <br /> and recycling systems) <br /> 4 <br /> 20. esignaledPacility Owner01 wwoolor Cerificum of recap,of hazardous �l�Il is covered I I IIIII ON <br /> except as npetl in Ile lop'! <br /> tl <br /> 'A Form 8700-22 V.a-va) Previous editions all Ils lete. H. on Day Year <br /> 03-01 - 13A08 12 RUD DESIGNATED FACILITY TO GENERATOR <br />