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4;• <br /> r.. <br /> .......Ilia, <br /> Ploasuprint or typo, Form designed for use on off to tit-pit typowrller. <br /> ) FormAppmvr:d.QMEt No,26514039 <br /> UNIFORM HRDOUS 1.GoneralorlD <br /> AZANumber 2.Page 1 of 3.Emorgemyfteeponso Phone 4.18 nif s1 ac In u J <br /> par <br /> , <br /> WASTE MANIFEST .A- 7;a ,r.� , � ;_7. � y, ; 496 J <br /> 5;Genarolor s Name and tAdiling Address Generator's Silo Address(11 different than matting address) <br /> +W)S. ;acfar'r7emo i <br /> E ijdi,Cls `15246 <br /> Ganarata sPhone ' •zd•d ati <br /> 6.Transporter 1 company Namo US.EPA ID Plumber <br /> 1'kAtvtt]�f:i;tt.+IR�AiL•kl:fJT':'.L�c:fiti.IC�^ i^.:.t �7:14f1�1�ri1 . <br /> 7.Tngi er 2 Company Name / r U.S.EPA ID Number <br /> 8.Doslgnaled Facility Name and Sita mdross {E-014-kES, TECYPA'A' LC US.CPA td Nvmbor <br /> I <br /> NC�4Un <br /> RVily7E7h1E7,GIA P;:_'Lf <br /> FaciLtysPhone: <br /> ga. 9b,U.S.DOT Descriprlan(including Proper Shipping Name,Hazard Gass,ID Number, 10.Contafners 11.1blal 12.Unit <br /> jilt and Packing Group(!f any)) 13.Waste Cndos <br /> No. Typo Qwmb'ty WlNfof, <br /> Yi;l I i <br /> A _ C1tu7 Fr t ttilfit alit; <br /> `dfsl.tU,rttif�i, G. F'GU1 <br /> I <br /> LU <br /> i <br /> a. DEC 2 2 2015 <br /> 14.Specht Handling Insbuctions andAdditional Information 1 <br /> JE1•;ir';;:tf1e�°;4 jr.5�.-1«'^�" fift:33fr:' '{ k�+•� �� f -�� ("?�'"�1 <br /> %:.P, �i3P1:,'�'r+.i;tlri Jr•,',kIvlrt; EAJ'v'1(rr•�t:jir'I�iuiA.i, <br /> lis NDLE R1;z;f•lfd;A.D k?E:1-i P44ED NII 11:11 P*E: <br /> 15. GE-NERATOR'6tOFFEROR'S CERTIFiCAT10N:i hereby dedave that the contents of this consignment are flOj and accurately described above by the eloper shipping name,gal Rre de6sirled.pacWsged. <br /> marred and labeleWpiacarded,and aro in all respects in properconditkm for banspod according to appkiihla international and national govemmenlai regsialigns,deat;ort shipment and 1 am the Primary <br /> Expoiler,I certily that the contents of This constgnmam conform to the terms or the aitachad EPAAchnmxledgmeni orco%ent. <br /> I lenity that the vfasta niWonizaWn statement identified MO GFR 26227(a)(d 1 am a targe quantity generdrarJ or(b)(if t am u smelt quanbty.ganeramr)is true. 1 <br /> Gana^taesioifetoes PdntadtTyped Name SIT= <br /> ''•� Month Day Yoar <br /> -1 16.fnlernalion ipmenls ❑ f. 1 <br /> tpraa to U.S. ❑Export hem U.S. Pod of <br /> Transporter signalure(for exports only): Date leaving U.S.: <br /> W 11.7mnspadarAcknoxktfgmenlofReceipt ofWerats <br /> otter 1 PdnledJr arae g_ � h onlh Day Year <br /> � ?� Si ahrrb'' r' t <br /> Transporter 2 Print yped Name r r 141' f',L <br /> ,.- f /" Sgnalure d1onlh Daty YearS1 � Ls <br /> 131, <br /> 18.Discrepancy <br /> 18x.Discrepancy Indication Space Quaniit <br /> Y ❑Type ❑Rasldun QPadlai ReJocllon ❑Full Re)ectian <br /> fdantrast Reference Number. <br /> t6b.ltltamatoFacility(or Generator) t1.S.EPA IDNumber <br /> U <br /> 1w FaCtRy's Phone: <br /> 16c SignaturecfAltomalo Vacility(or Genorator) Month Ray Year <br /> N 19.Hazardous W <br /> ast)e Re/port6lanagament hletiod Codes(i.e„codas for hazardous waMe treatment,disposal,and recycling systems) <br /> W 2. <br /> 7. {`t f lI/ 3. 4. <br /> 24.Cesignaied Facility Owner of Operator:Certfiic con of reteiptof halantetr materials covered by the rnenftest except as noted in Item f 8a <br /> Pdfl!eedff y^p�ed Nome __ tura . monul /Day <br /> earl <br /> ' (r".�1t�rc"" r� }%7�i!'?� �'1..8• +�.ar�6�,�:i.�.Y.. �',( EJC! l <br /> EPA Form 870D-22(Rev.M5) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />