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P <br />I <br />Tre <br />18. <br />Fa <br />y., <br />t. } ' e . <br />designed for use on elite (12 -pitch) typewriter ) .. Approved. OMB No. 2050-0039 <br />US f. Generator ID Number 2. Page 1 of 1 3 Emei ;ency Response Phone 4. Manifest mlber <br />j "?7 <br />.1. V <br />2 GBF <br />Gene, . is Site Address (if different than mailing address <br />iadmg Address <br />I <br />' ydA Wf)d i a 4►%2�t1 <br />— <br />�� rdrs U.S. EPA ID N <br />+�r19 41 ra` i4y f ,,. I�Y� •. A + '1� .� i.AFf i_7 <br />U.S. EPA ID N <br />+ame <br />Name and Site Address U.S. EPA ID Nt <br />...1tntkrildi} %''la1[t1.Js: ✓r'+;r71 [:.•'+�Y + 0 ^R)! <br />i <br />fs <br />)escription (including Proper Shipping Name, H$zard Class, ID Number, <br />roup (if any)) <br />10. Containers <br />11. Total <br />Qu/�annttity/� <br />No. <br />Type <br />ti<i;.3t+a+pt::, �.::+u .i.11,, + ,tj <br />I `ld•':t.b7%' 1°'f�'i; 'R''i ' - <br />•� �..A {T. <br />(•. n� <br />`J C) <br />i j, waste uooes <br />I <br />Instructions and Additional Information <br />EROR'S CERTIFICATION: I hereby declare that the contents of this consignment, fully and accurately described above by the proper sF and are classified, p ckaged, <br />,d, placarded. and are in all respects in proper condition for transport according to a ic. 'Ile intema .one] and national governmental regulations. II ort shipment and I am the Primary <br />that the contents of this consignment conform io the terms of the attached EPAAcknbwi' ' 7mgnt of Consent. <br />waste minimization statement identified in 40 CF R 262.27(a) (if I am a large quantity gen,.r aor) 8t o) (if I am a s II q tity aerator) is true. <br />Month DP Year <br />Printedfr d Nam Signatur� I { ,., <br />rents <br />❑ U S — -- <br />Import to U.S. ❑ Export from S. Port of ehuylAxit— <br />e (for exports only): `Qate leaving U.S.: <br />owledgment of Receipt of Materials <br />'y me i ,du 4 Mq .D Ya" <br />IL �`� ., <br />t1r <br />ed/Typed Name Signature Month Day Year <br />+ication Space F-1 quantity ❑ Type ❑ Residue ❑ Partial Rel. ❑ Full Rejection <br />Manifest Reference Number: <br />y (or Generator) <br />U.S. EPA ID r, <br />8 "ornate Facility (or Generator) <br />i <br />e Report Management Method Codes (i.e., code <br />A <br />2. <br />ility Owner or Operator: Certification of receipt of <br />Pr :)e <br />A Fc Rev. 3-05) Previous editions are obsolete. <br />for hazardous waste treatment, disposal, and recycling systems) <br />3. <br />azardous materials covered by the manif :st except as noted in Item 18a <br />Signature <br />4. <br />Month Day Year <br />1 1) 1 1 <br />TRANSPORTER'S COPY <br />