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7 <br /> Farm Approved.OMB No,205NO39 <br /> Please pnnl w type ;Porn des"rrep la use on eine(12 g1t'hI IypawnlU[j 4.Mani Tryack1ng INornew <br /> UNIFORM MA7AR000S t Gunuto 0Ndwcor 2pares ld ).Emerae"cY Response Phone4 P 5' JJ K <br /> WASTE MANIFEST I a.. 3 <br /> 5 eewraays K.rW Will,Amba>e GenaragYs sde Mdresa IJ digarml than matlmg address) <br /> L r <br /> cln.aiors phones r a U5 EPA 10 Nember <br /> 6 Tmnspodw l Company Name .�. <br /> ll s EPA ID Namber <br /> F TrL,saorer 2 Carl Nemo <br /> , Us BPA ID Number <br /> d OasgnaNd Faaliy Name and Site Address <br /> faclliPnone. <br /> 9a AC U.S WTOesuipoon ixitladmg Pmpersnppmg Name.Haswal Claes.fO NU-w' 10.Cmminurs 11.Tocol 12.Unit 13 Waste Codes <br /> HM and Pazioi9 Gmee(+mylt No Typo Duanury Yvl i�b�. <br /> ¢O <br /> W 2 <br /> WU' <br /> 3. <br /> 4. <br /> fd Spi Handsel lreWclgnsardditi nbrmelron <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I herepydedare coreaarinentarefullyard awmteby dewibed above byte proper s ppngraai and are c'wadled,packi <br /> mailedandabel.Ngacarded.are are in all respeas in paper mndalon for transport ecccrding b applisse temaoonaland nalional governmental regulations.If export diplrenl and am me Pauli <br /> Examen.I andav all,the mnbdsaf this corns ra ant saearm to Ira!erre of me Model EPAAckrtoMedgmentof Central. <br /> Ia*mal the waste mrestoesm smmmenl deneted in 40 CFR 25227(a)(e l am a Islas quantity genaamUa Y(dI am a smell quarlity geresalor)is We. <br /> Gmaatorsl0eemrs PrinmNyped Name hke f1i bay Year <br /> F 16.Inmmaaanal Shipments ❑ portmus <br /> m ❑Expod con U.S. PaldenbyRxft. <br /> Z Trensmderslgnwere(fe'exparmonly). Gets leering U.sf: <br /> W117 fmrepoderAdrroMmgmen!M Receipt of Na'snals <br /> Transporter l P,nladTyped Name Signature Mont Day Yew <br /> O <br /> 6 <br /> TranspoNp2 rrueGTyped Name sgnai Month Day Yew <br /> 1e Discrepancy i 18a.Disoepancyindiwuon Space F-1 Quantity 11Type D Residue ❑Parral Re)ecoan ❑FNI RejKUon <br /> Manifesl Reference Number. <br /> lab Pheresis Fsafty fa Ger emmr) US.EPA ID Number <br /> 7 <br /> V <br /> sai FarYaya Phone. <br /> Ise SiMme of Alternate Faduy'(or Gerai <br /> a Moth Day VUaz <br /> y79.NazaNan Warm flepdn Mar'�wllAre Method Codes(re.,codes for hazallous waste teatm ent,disposal,and recycling systems) <br /> � 1. 2. 3. 4 <br /> 1 20 Designated Facility Omer or Operator Cerakaeen of wall of hazardous maters covered by are mans est a ceps es nosed in Item laa <br /> cin yped Name Spnature <br /> Month Day Year <br /> EPA Form 87X-22(Rev 3.05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />