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Rleesty-pth Ibr type.(Form,esigned for use on elite(12-pitch)typmriter.)i, Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZAROOVS 1 GenemloflONUmbef 2 Page i of 3 Emergency.Response Phone 464lildifest Tm ing Nu barCLC C <br /> WASTE MANIFEST Cli3-Q9215IK '' '<'-R••�S�•:s:`Jv V0 1 012 1� <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> )'-C'rii erl ifTO, <br /> 'CLUS 91 VO <br /> r::F;e;`I.7 SmCitu Pa'fu^(�i3Yi}0 i.;,�. E7.�i',�88 '�r1 d•0.',�•�2('i: `�'�`:(i!_;��'; i.:"1 '�s"l <br /> Generator's Phone: <br /> Transporter t Company Now US EPA ID Number <br /> 7 Tra 2 Company Name U 3 EPA ID Numher <br /> 8 Designated Faaldy Name and its Brass 14 US EPA IC Number <br /> u;::E4"w;,, sOerabfm <br /> M' cry = <br /> t,es,5 ?%m <br /> 1 <br /> FacliftyPsPTlone: 77.ry-?Fr,721S <br /> gy 9b U.S DOT Description(Including Proper Shipping Name Hazard Class ID Number 10.Containers 11 Total 12 Unit <br /> HM and Packing Group(it ani No. Type Quantity WWof. 13 Waste Cad. <br /> z 1 Saiic't, C,annn.w,in n ?),1 eS i, _" 362 l <br /> XI r P _....._..___ _. <br /> z 2 <br /> w <br /> V' _.......1.�. ._ <br /> I ( <br /> 3 <br /> 4 f <br /> 14 Special Handling Instructions and Additional information 'y°SI'A. AL.I f4(''PRIC✓PFO.1.f1'T; R )"l(S'370 <br /> 1 r .1 .=' 'I j„� .n I�11 r,^ft Y.EEr-111':J ' l'.'t. lF!It1:t:. <br /> 15 GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described shove by the proper shipping new,and are classified,packaged <br /> marked and labeledlplacarded.@EA are in Ell respects in proper condition for transport according to applicable international and national governmental regulations if export sHpment and l am the Primary' <br /> Expoder,I certify that the comantsof this consignment corrfortn to the terms of the attached EPAAcknaMedgment of Consent <br /> I certify that the waste minimization statement idenMed in 40 CFR 26227(a)(if l am alarge quantity generator)ur(b)(d l am a smal 5 tity generator)is tore. <br /> GanisameshOffemi PrintedlTyped Nam gna re ,{ Month._,"'`� { ^D y ear <br /> JP G$;'-3, ::f''. Fri?r3��7'` rcY;P:dLiFY' �+�W.n..„,,.+ 1✓ L.6' 1 <br /> J 16 Interrellonal Shipments <br /> F ❑ImpodloUs ❑Export from U3 Ponafentry/e' <br /> ? <br /> Transporter sinnature fief"Pore pnl). De vin U.3: 1t <br /> w 17.Transporter AcknovAittmentof Recalls of Materials ( _ <br /> Transpoderl Prin yped Name f- Signature I '•� on ay Year <br /> QTransporter 2 Pdntileyped Name gna re , `� on Oay e r <br /> r <br /> 18.Discrepancy <br /> t 1 B Discrepancy lnd'cetion Specs ❑ quantity El Type Residue j j <br /> ❑ ❑Padiel Rejection ❑Full Re eGlon <br /> Manilas[Reference Number <br /> 18b Alternate Facility(of Generator) US EPA ID Number <br /> J <br /> LL Facif 's Phone: <br /> USzoa <br /> W 18c SignatureofAllemata Fwc itylor GenemtwI ,Mnntn Day Year <br /> Q <br /> z <br /> S2 19.Hazardous Waste Report Management Method Codes(i.e.,codas for hazardous,waste bealmenl,disposal,and recycling systems) <br /> 1 1 2 3 4 <br /> 20.Designi Facility Cliyyp rOpRralor. ca ono receipt ofhazardous materials covered by the manifest except as noted in Item IBE <br /> Nni Name/ _ f Slgnalurel. . � M ih Yee <br /> EPA <br /> Fowl <br /> orm 700- 2(Rsh), -Preieditio s iratii I �DESIGNATED FACILITY TOGENERATOR <br />