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it or type,(Form designed for use an G"Lo" -pitch)lypewribir.) Form Approved.OMB No.2050-0039 <br /> UNIFORM H=S 1.aeneretar ID <br /> WASTE M 2.page I or 3.Amewcy R,9,,8onse Phone 4.V[ajffljTjiI?kIng Number <br /> 5.GarjTr 037 21 JJK <br /> Generators Phone <br /> 6.TT"- I- U.S.EPA ID Number <br /> T., ��. Tr 71,N-", - r r) <br /> 7.Thwarted,2 Coargart,N"'' I <br /> or Nunblc <br /> 8,DO" <br /> U.S.EPA ID Number <br /> Faciii ys Phone: <br /> 5 5 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Nam,Hazard Claw,10 Number, 10.Containers 11.Tidal 12.Unit <br /> HIM and Padding Group(If any)) 13.Waste Codes <br /> No. Type Quantity VVUV0L <br /> 0 <br /> z 2 !11,r-Hv--�-'A HSZarjoj Alill <br /> I -53. <br /> (VOAI F-ClIZA 1-0LC%I"0,4J \o#Jco+c 5C,h a <br /> C-0 11 �,1 1+(,(5) - 2 <br /> ' NON ?-CLL 14l Crus W"e- Ir urs 31 <br /> C 9 het"F—,y 14 <br /> 14.§R@ Handrr�,rjuimrag end AryfIiogIjrAwrkobpn <br /> snotPc:af.lj.e tf, q�a, NP:? <br /> S` <br /> I.CA ins I "Ic . <br /> A b-3 C71 Ffc-f, le4=rlk //64ill 55 trb"Ys hr"Itk:O/W,*�I wilpiel 02 <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the Proper shipping name,Ord are classified,packaged <br /> marked and labeleplacarded,and are in all respects In proper condition for transport according to applicable international and national governmental regulators,If export ONPoland and am he Primary <br /> "I <br /> Exporter.I cwJfy that the contents of this consignment confomn to the terms of the attached EPAAcknowkedgariont of Consent. I <br /> I ratify that the waste minimization statement denti in 40 CFR 262.27(a)(if I am a large quantity generator)at(b)(If I am a eeellquantity generator)Is true. <br /> rs arm Name 7, N Yew <br /> L� <br /> e/-j < <br /> I!!ng )L�tt�4� <br /> 16.International Shipments E.Imit fr..U.J. P oil of ani <br /> LImpoittoUS. E <br /> Transporter signature(for witaft doll, Data Waft U.S.: <br /> Ix 17.Transporter Acknowledgment of Receipt of Materials <br /> 12 0 — <br /> lmrcilrwonev <br /> Zh Tran z FIVIIINYTYPed Name <br /> sun <br /> Month Day Year <br /> Iq 1 '/ 1 / 7 <br /> It.Disc pen <br /> 1 Be.Discrepancy Indication Space El QuanUty El Type ❑Residua D P.H.1 Rejection Full R.jeckoh <br /> 18b.Alternate Fadify(a Generator) Manifest Reerince Number. US.EPA ID Number — <br /> zi <br /> 0 <br /> LL Facility's Phone: <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(I.e.codes for hazardous waste armunwt,disposal,and recycling systems) <br /> 1 20.Designated FacOry <br /> MUNI/Typed N w Operator Carlificallon of recelict of haaardaus materials covered by the manifes(except as acted In Item Its <br /> done Signature Ye <br /> EPA Form 87&22(Rev,3-05) Pm7l—m a editions are obsolete. <br /> DESIGNATED FACILITY TO GENERATOR <br />