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_ 7ha Qo W Con elite(t 2-pdch)typewnterj -.'.r �.'•].rr �� <br /> ta <br /> j•a��o a , _ 4 <br /> i�.s�#fl�nrannaA 2 P�7a I or J Emrryonq P,esWrn;e Prr,,,. 4 rAxni r r .!AP 11•,i <br /> JJK <br /> Gr3�-ra ^F i Comrany Nis— - <br /> -;ranspa'ter 2 Company Name <br /> ,trot.o•b-r... l <br /> 8 Dessgnaled Fatality Name and Ste Address U.S EPA ID Number <br /> US EPA ID Number �Ir✓ <br /> Facilty's phone: <br /> ea. ab U S.007 Deu (if any)),j(nJutling proper <br /> HM and Packing Group(N aShipp,ng Name.Hazard Class.ID Number, <br /> i <br /> O Typo :';yste LrAes <br /> W 2 �. <br /> 3 <br /> 4. <br /> r• 14.Speda,Ha-r;tn]lnslructions and Addiucnal lnrormaLon <br /> r••r <br /> 15. GENERATOR rkeda 'SlOFFEROR'S CERTIFICATION:I hereby declare that the contents of this coni gnmenl are fully and accurately described above by the proper shipping name.and are ciassitied,packageo <br /> . <br /> marked and labeleNAlacarded,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 Primary J • <br /> Exporter,I certify that IM contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> a Ice"that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity,generator)or Ib)pt I am a small quantity generator)is true. <br /> CD <br /> Generator's/Offerors PrintedlTyped Name <br /> CASignature Month Day Year <br /> 16-Intemational Shipments - <br /> ❑Import to LLS. ❑Export from U.S. Port of entry/exit:fD 7ranspodcr signature(for exports only): Dale leaving U.S.: <br /> a TrnsponerAcknowi menl of Receipt or Materials <br /> er I Printed7ped Name Sgnature - Month Day Year <br /> i <br /> transporter2PrntedTypedName Signature Month Day Year <br /> ptcrepancy <br /> repancy <br /> 1.4 t lndicabon Space Ouanlry Type ❑Residue ❑Partial Refection ❑Full Re)eclion <br /> Manifest Reference Number:Allerna(e Facility(or Generator) U S.EPA ID Number <br /> O <br /> phone: <br /> lWiattrrie OfAltemale Facility(or Generator) Month Day Year <br /> � zardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 2. 9, 4 <br /> D �• <br /> f-- gnated Facility Owner or Operator:CerdcaWn of receipt of hazardous materials covered by the manifest except as noted In Item?Ba <br /> (Q ryped Name Signature hlonh Day <br /> 00-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> N N <br />