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Please print or type.(Form d T C. 2 `�d 2 . 1 6 <br /> esigned for use on elite(12-pitch typewriter. Foran Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1'OQnGahr ID Nmrdw 2.Page 1 of 3.Emergency Response ph nu, 4.Manifest Taddng Number <br /> WASTE MANIFEST 9 0 -� 0 0 5 2 318 0 2 JJ K <br /> 5.Gearamys Name and Maifmg GeeraWs Site Address(d dMerent than ma9bg address) <br /> OU, c/a 3 coni n- <br /> 3Zo} (, �,� lbls�t ri SI,Te I lC`O�iudi RJ_ <br /> Cn¢►s64�d ,Cit- Cl2A to nw1r1 ' ck iSzIS <br /> GearatWs Phone: <br /> 6.TrartsOoRer 1 Company Name <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Canpany Name I D 13HZ <br /> W <br /> 8.Desi9rated FaaLly Name and SileMMd<ass - R. ,.rya r U.B.EPA ID Number J <br /> Ib10 W l�'11'L <br /> i o 4h 9"d{ca, 01813 <br /> F aPhme: 9-010- -b i Z, 0901c) <br /> ga_ 9b.U.S.DOTDesaiptiar Imduding Proper SlupPmg Nance,Haerd Class,lD Number. 10.Containers 11.Total 12.Unit <br /> HM and Padug Orap(d any)) No. Type Quantity 12.Uni 13.Waste Codes <br /> c ' POD- ¢dOvJ �Q�Cb (.O�;v� 8l O�1 2C7 LL <br /> 221 <br /> WZ �' OVKZ0�Sal n p i M 3SD Q <br /> z <br /> 3. ss <br /> 4. <br /> 14.Spada)Hand"11 butructiaa antl Additional bdarnlmon <br /> 0 &Obli3 <br /> DvZ5�I�G <br /> AbSa1W`t - lo:�, BQSri� Z� - <br /> - - -- - - - -- - - - -- - - - - - - - - _ — - - �(.�-911} <br /> 15. DENEd and la SIOFFFRDR'S CERare,in all res I terelrydetlae that the Contents of this mnsignrrert are filly and accurately desamed above by the proper shipping name,and are classified.Packaged, <br /> marked and abeled ,and are a all respects m Proper condition for bmspcd seconding m applicable mtematimal and maorel <br /> Exporter,l cad*that the contents of this aattignmem midam to the hurt¢of the attatlid EPAAdaiwAedgment of Consent garenuranW�ryadons.If export SNpn1eN and I Con the Primary <br /> 1 cantly gat 8a waste mmmr®tim statement identified!in 40 CFR 26217(,)(d I am a lave quantify,gen.. 0,@) I are a small quantity gem radar)is we. <br /> GerareWs/ s Fyinted/7 ane Signature Month Day- Year <br /> M' <br /> J 16.international merits <br /> Z <br /> LJ import to US. ❑bpm from U.S. Portofentrylenl <br /> r sg : <br /> Trdrapove rabae(far appts only)' Dale leaving U.S.: <br /> w 17.TraspaterAdwowteOgrnenl of Remo of Materials <br /> Vanvortff1 PmrteNf ,/ y�j ''7 <br /> m0 yped Nana Skyahre V" ` ! Y Y <br /> A vi �Q <br /> QPnnte&Typed Nam ria <br /> d, Month Day Year <br /> F Q� <br /> i18.D'saepanry <br /> 16a.Discrepancy liK iWGm Spam ❑ Quantity ❑TYP. ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 18b.Monare Facility(a0erieeter) Manifest Reference Number <br /> J <br /> U.S.EPA ID Number <br /> U <br /> Faalilys Phone: <br /> H1&.Signature olNtertate Fardity(a Generalar) Month Day Year <br /> Q <br /> 2 <br /> W19.Hazardous Waste MarageranI Method Codes p.e.,codas for hanrdpa waste beaanerik disposal,and recyc[M systems) <br /> Z / 3. 4. <br /> 1 20.DMVW F Ce cation Of rsc*of haaNae materials arveed by the mvtife5l accept as noted In Item 18a <br /> PdnWgyped SkpaGrm <br /> Vf <br /> FPA Forma 00-22(Rev viola Chats are tan. DESIGNATED FACI TO DESTINATION STATE(IF REQUIRED) <br /> 11815.1839 <br />