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Nov Oa 11 12:13p • P.10 Please Print or We,Forrin designed for use on elite(12-01ch)typewriter.) Farm Approved.OMB No.205D•0039. UNIFORM HAZARDOUS 1.Gerierator(O Number 2.Pago 1 or I rr�eqsrcy R!s!.7 4.Man-ifiest TMking Number WASTE MANIFEST ELE 5.Generator's Nam and MailingAddresss r Generator's Site Address in different than mining address) Gel anal Phone' any Name US,EPAID Number T.—7nn3pater 2 Company Name U.S.EPA ID Number a.Designated Facility Name and Site Address :U.S:.(:PAIO Number Facl Phone: 9a. 9b.U.S.DOT Description Crtluding Proper Shipping Nam,Hazard Class,10 Number, 10.Containers it.Total Q.Unit 13.waste Codes HM and Pecking Group(Namr)) No. TV, Quantity WWII. L Z Z. lir .-v................. dD dAdcritimmi ofictinift-0—n 14.Special Hancloginstsuchoris an 15. GENERATOR'SIOFFEROFVSCERTIFWAnON: I I'Velty declare that We contents Of thillwier:911memt are fLfily and accurately descrited above by the orepershippiriol name.and are desSilieck packaged, marked and labeled'plivanded,and are n all respect in proper condition for transport according to applicable international and national governmental regulations.if export shipmene.and I min the Primary Exporter,I ceitly that the contents of this consignment conform to the terms ouve attached EPAAcimmuledgment of Consent. I mfdy that the waste rominiutem slateereal Idendked in 40 CFR 262.27(a)(if I am a large quanfitr gemamor)ar(h)(if I M a small quantity 90fleralor)is nue GmegatcesionemesRiot eciffyp Name Signature Adarnn Day )h" + 16,Internatio nal SHpment5Elporl fr.U.S. Pon of en by/eXit: El U.S, Transporter vornature(Mex ens on Date leaving EJ.S,: CC 17.Imrsporter Aclanowledgmand at Recelp(of Materials W Signakee, Month Uay Tear Tmnspic!ter I Prmted�y ped Name 07Signature.: Month 51j Tear QTm—nswrler2 Pnnted/Ty*New la-Discrepancy 1 Ea.DisChapanCy Indication Spam citionfityr EITYP. Residue ❑Partial Rejection ElFull Rojectu Marifest Reference Ninber. 18h Mesmate Facility(a Generator) U.S.EPAID Number W 18u SignaWre of Alternate Fadly(or Cmemflior) %konll Lav Yea: Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes lor hazardous waste trimmerk disposal,and reG),di:1g systems) 2. 3 120.DeSignated Facpiy OWMrQr Operator,Ced[ricatiDn of receipt of mmtricus materials covered by the manfirsLeiccept as noted in lem last identh Day Year ri��"�ed Name Vilmature EPA Farni 87OD-22(Rev.3-05) Previous editions are obsolete.