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1:' N <br /> xi'ob �� p F run use on elite(12-pitch]typewriter j <br /> S ` r Generic ID Numner , 'may'' <br /> (D FQ w <br /> 2 Page 7�I 300 <br /> Fme.yer'q'Res <br /> R.rm Appro/ed DMB II 1J` <br /> W-. antl Ala a:nCA iG,=•.:: Ma <br /> In <br /> - < nlnsl lratk,n3 Number '�1 <br /> r 9 JJK <br /> ra's Phare: <br /> unsPone/t Company Names <br /> iransppner?Company Nam= U 5 EPA!D N--, r <br /> 8.Designated Facility Name and S to Addre,, 115 EPA ID Num;;ar <br /> u i F Pc.I D'..:n bar 1�I <br /> F-01TYs Phone: a <br /> 3a gb U.S.'OTup (n Judmy P <br /> HM ano Fackm Grop( a,, roper Shipp,ng Nanta,Hazard Class.ID Number , O <br /> ,,I <br /> Q� Tipa 13 Vlasl2!'ro> I — <br /> W <br /> Z 2 <br /> LU <br /> � did <br /> V <br /> � 3 <br /> �I <br /> rr- a I� <br /> r�/1• l V <br /> • f<Special Nandhng lnstruq:ens and Additional Information [^•I <br /> UQ /r s' h� <br /> t 15 GENERATOR'S10FFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and fabeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations-If export shipment and I am the Prmary� V, Exporter.I certify that the contents of this consignment conform to the terms of the attached FPA Acknowledoment of Consent. <br /> I cendy that the waste minimization statement Identified in 40 CFR 262.27(a)(if I am a large quantity generator or h ill am a small uanU <br /> rp Generator'srOBerors P ntedR ) I)( q N generator)is we. <br /> yped Name Month Day Year <br /> v� Signature <br /> 16.International Shipmants <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylexit _ <br /> I+. Tr naponer signature(for exports only): <br /> 171) Dale leaving U.S.: <br /> Q. 17 Transporter Acknowledgment of Receipt of Materials <br /> 51 Transporter 1 Printedrryped Name - Signature / <br /> _ .. Month Day Year <br /> Transporter 2 Printed/iyp-d Name <br /> s^7 Signature Month Day Year <br /> C ).Discrepancy <br /> a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Releclion <br /> Manifest Reference Number: <br /> —UW(ernata Facility(or Genera-for) Manifest <br /> EPA ID Number <br /> 3 <br /> O <br /> 0 ty's Phone. <br /> O <br /> 1- >ignalure ol'Alfemate Facility(or Generator) ---7 <br /> Month Day Year <br /> C <br /> Izardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 2. 3 4 <br /> D - -] 0I• <br /> ignaied Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noled in Item 18a <br /> typed Name <br /> = Signature Month Day Year <br /> <n <br /> 00-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> lowC) N <br />