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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved OMB No.2050-0039- <br /> 1.Generator um <br /> ID Number 2.Page 1 of 3.Emergency Response Phone a.Manifest Tracking Number <br /> ARD <br /> UNIFORM HAZOUS �' t r ! JJ K <br /> WASTE MANIFEST CA'Ls CKJO 3 t>3 1 63 � �� ��r �1.:"'`3d a? <br /> 5.Generator's Name and MallingAddress Generator's M Address(if dgkerent than mailing address) <br /> ?t"s:U?r ' Gas t ♦� //, (� <br /> `�VS1 . �r.4 rLib f`�4ul LF4di. C1 9524Lr <br /> Genwalo/ifs Phow 0,16),- 2 5776 <br /> 6,Transporter 1 Company Name '� U.S.EPA ID Number <br /> .t.: <br /> _ � .v,';i>i+:;iSTt`s SERVICES F,•c12 xl" (03 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address pp ppU.S.EPA 1D Number <br /> " �ii'rr�: L:4�a Li?liYi�.ii:lb'I.,tliJ >l�.�A?:.1.pii•ii.4 . <br /> ,1515 x'tii`1UT11 -9-VF:+. Kier I), ii EST S_1050-E:1IF0, CoA 13.5 �oI <br /> !141% 044 <br /> Facility's Phone 3,;-5747 <br /> ga, 9b.U.S.DOT Description(Including Proper Shlpplrg Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) _ No. Type Quantity WLNOI. 13.Waste Codes <br /> Cr Z-5 <br /> a� <br /> W <br /> Z 2. <br /> fY <br /> t,7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> rAINDLERS TO -U TRAINED M0 USE <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this mnsxdnment are fully and accurately described above by the proper shipp;ng name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable internacional and national govemmental regulations.If export shiprnent and I am B:a Primary <br /> Exporter,I certify that the contents of this consignment conform to the terns of the attached EPAAcknowledgment of Consent <br /> I certify that the waste minmization statement Identified In 40 CFR 262.27(a)(d I am a large quantity generator)or(b)(gl am a small quantity generator)is true. <br /> Generalor'slOfferor's PrintedlTyped Name Signature Month Day Year <br /> .1 16.If4ernatonal Shipments <br /> F ❑Import to U.S. ❑Fxportfram U.S. Pon of entrylexit <br /> Transporter signature(for exports only): (late leaving U.S.: <br /> W 17,TransporterAckmviedgnent of Receipt of Materials <br /> o Rf <br /> Transporter 1 inied(Typed Name Signature Month Day Year <br /> H /i/r l .�11,' � r" 'ted �.Y a 17 <br /> Z Transporter2 Printedlryped Name Signature Month Day Year <br /> OC '� <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El <br /> Quarrsity El Type Residue Partial Rejecter ❑Full Re,'ection <br /> Manifest Reference Number: <br /> 18b.Alternate Fadity(or Generator) U.S.EPA ID Numbe- <br /> J_ <br /> t� <br /> LL Facifty's Phone: <br /> W 18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> Fn 19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by tine manifest except as noted in Kern 18a <br /> Prnted/Typed Name Signature Month Day Year <br /> EPA Form 870022(Rev.3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />