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use on elite(12-pitch)Wown:er l <br /> G!F-alor ID Nrmher u <br /> ( • :• - J P,Ire I pl <br /> �yYMM III aACINe::s -'r t9�".Y Ne.,f••.�PFnn< a Mamf.s Ep,!ad OMEN . 1t <br /> 1 iracF nggg mb,l uher <br /> 7 JJK <br /> '9a,LVas1 �. <br /> Genmarors Phone <br /> _ ,fir 6 Transporter t Wmpany Nan+e <br /> Company Narne IS EPA ID Nim , O <br /> e.Desnnated Facl:ry Name and SIte Addre;y I1 S EPA ID Niimn, F� <br /> . _. u S EFA ID <br /> Faohn's Phone f.. <br /> 9. "'S.Dti DeschpUen(:nciuding Pm"Snrppl.y Name.Haram Cuss.ID Numher. <br /> 1 .n+Packng Group(if am•)i <br /> IO ccrt,'�, .. <br /> O c it Pe 13 NaSe.CWe <br /> Imo• W <br /> W <br /> for <br /> Frtp +a`p""a'Nagdlm9 trlsnuchons antl Addn:nnal Information <br /> CD 15 GENERATOR'SrOFFEROR'S CERTIFICATION:I hereby declare that the COVents of ebs c <br /> rte., matted and IabeledipWyrdei,and are in all respects in Proper coneilion for trafrpot axordt omem are fully and accurately de5lm:ed avow by I„e proper smpwg rime.and are tlassF•ra, <br /> Expoter,I certdy that the Contents of his <br /> conconform to the leans of Ilia attached E AAcl;ncwledbgrnenl tN oraro natphnal gzwmmental tta7uklons.!t eryort sh, packageu, <br /> I cert pm:em are am:he Pnmary <br /> fy that the wade mmim¢alwn statement identified in 40 CFR 262.27(aJ llt 1 art a large quana <br /> Generatofs'Oflerors PdnfeaTyped Name generalc')or ib)('ll am a snail quan4ty gererala)rs In,e. <br /> &gnaturz, <br /> Month Day Year <br /> -u 16.International Shipments I� <br /> ~ rl Import to u.S. r� <br /> Transporter signature(fur exports only): f E.”fmrn U S Pert of antrylem <br /> �• 17.Transporter g PI of <br /> �.. w Mied menl of Receipt <br /> Ir Transporter 1 Pnnledtiyped Name <br /> O SpnaNre <br /> A N ,. _ _ mcip"'t, Day Yrar <br /> C a Transporter 2 Pnnied/Typed Mame <br /> 'r S-enat:n e <br /> � 0.fonm r,,,; vaar _ <br /> 18.Discrepancy <br /> ida Discrepancy indication Space <br /> ❑Quantity LJ Type Res:uw Fj Partial Rejection!� ❑Full Rely iwn <br /> Atarulnsl . <br /> 0 � 186.Alternate Facility(or Generator) Reference WnibeiU S EPA ID Nun#•r <br /> O =' <br /> U <br /> 1 Facillly's Ptrorw' <br /> F18c Si9oalure olAllernale Facility(or Generators A <br /> z <br /> Month Dao 1'0ar ( 11 <br /> Z <br /> 0 w 19.Hazardous Waste Report Management Wthi](1 Codes(i a.,codes for hazardous waste Itealment,disposal.and recycling systems) <br /> D 4 Ir r• <br /> 20.Designated faculty Owner or Operator.Certification of recelpl of hazardous materials covered by the mandest except as ncled in Item 16a <br /> PWOVtyped Narne Signature g Month Day Year <br /> C31 <br /> 00-22(Rev 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY �Fd� <br />