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r.•1 <br /> a . <br /> PF�prRrr tLpr type.(Form designed for use on elite(12 pdch)typewriter.) <br /> ". Form Approved.OMB No.2050-0039 <br /> Ulvl>ORM HAZARDOUS [11. umber 2.Pa 1 of 3:.Emergency Response Phone 4.ManifestTrackln Number <br /> 1hIA5TE MANIFEST <br /> �. �" n 04 8 F L E <br /> 5.Generalor's Name and Mailing Address a GeneratoCs Site Address(t different than mailing address) <br /> � At 9k 'r <br /> Generator's Phone I— a <br /> r6ransporter 1 Cofnpany Name U.S.;PAID Number <br /> f � a <br /> 7.Transporter 2 Company Name U.S,EPA ID Number <br /> 8.Designated Facifly Name and Site Address ' A y' U.S.EPA ID Number <br /> Facility's Ph.2 49 S - <br /> 9h.US.DOT Description(indudtng Proper Shipping Name,Ha2ard Class,ID Number, 10.Containers 1.Total 12.Unit 13-Waste Codes <br /> 9a' No. Type Quantity WWoI. <br /> KM and Packing Group(if any)) <br /> z 2 <br /> 06w <br /> 3: .� <br /> 14 Special Handling Insor coons and Additional <br /> GENERATOR'SIDFFERONS CERTIFICATION:I hereby declare that the contents of thls consignment are fully and accurately described above by the proper shipping name,apt are'classiped,packaged, <br /> i marked and labeledplacarded;.and-are In all respects in proper condition for transportaccording to applicable Intematienal and national governmental[egulatirxts.If export shlpmant and I am tha Primary <br /> Exporter,;I certify that the contents of this consignment conform to the terns of the attached EPAAcknowledgment of Consent <br /> 1 cerb(y 6retthe waste minimization statement IdenOfied'n 40 CFR 262.27(a)(if l am a large quenldy generator)or(b)(IFI am a small quantity generator)is Irue. <br /> neratar OBerorsPrintedrryped•W@me <br /> Signature <br /> ... ear <br /> 11 � �J d� / " <br /> r,rrrdtlonal Slupmenls ❑Import to S. ❑Exportfrtm U.SJ � Part oTleoaylexit <br /> TransportarslgnaWre for exportsonl): Date leaving U.S.: <br /> d' 17.Trarsporterk1nm0edgmenlofReceiptof'Matedals on ay ear <br /> ransporier Prnledlfyped Name. gna u <br /> ra. - `i 4i44071I n ay Year <br /> Si <br /> a ranspo r2 PrinteNfyped Name gnaNre <br /> 19.Discrepancy <br /> 18a.Discrepancy Indicatien Space ❑Quantity ❑Type ❑Residue ❑Partial Rejedlon ❑RAR*,jrlc_ <br /> Manifest Reference Number <br /> U.S.EPA ID Number <br /> 18b.Altemele Facility(or Generator) <br /> J_ <br /> V <br /> FacIG 's Phone: Month Day <br /> 18c.Signabre of Altemale Fadlity(or Generator) <br /> Q - <br /> Z <br /> S. 19.Hazardous Wasle Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 4. <br /> 20,Designated Facility Owner or Operator:Certification of receipt of hazardous malar els covered by the manifest except as noted in Item 18a <br /> Month Day Year <br /> Pnntedfryped Name Sgnature f <br /> DESIGNATED FACILITY TO GENERATOR' <br /> EPA Form 87&22.(Rev.3.05) Previous editions are obsolete. . <br />