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62!26!2663 15:36 KS-373-1172 W LTONFNGINEFRING PAGE 6z
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<br /> Please print or type.(Form designed for use on elite.(5xptloh)typowrlfec) Folm.Ap roved.OMB No.205G•0039
<br /> 1} UNIFORM HAZARDDIIS 1.Genrratot ID'umb r 2.Page 1 If 3 Emergency Reaponsc Phone 6,kuxnffaet TneHmg Numbor �{
<br /> WASTE MANIFEST �,": A r': tui 0 r g1 ; :'v'� ;i 1 ;" �) 1ndCl£7 i-�07.� 0.Q I ;(�.���"� JJ K
<br /> S.OelfOhtoYS Nmn9 and MBlling Atltlrees - Generntots Site Address pt dlramm than magin adamaa)
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<br /> Genomfis's Phone 2 0 SI ; ^y , 74, 7 0 (f
<br /> Vyan arbWr Cgmpony Nemo: - U,$.EPA ID Number
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<br /> 7.Tmnaporear 2 Componv Nsme -
<br /> U.S,EPA IDNumbor -
<br /> 1,�266) 1y�FaF1'117}�'. ofif�tl SlleAtldress ID- U.S.EPANumber
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<br /> gA 9b.US.DOT Do,cdptson(Includlrgl Proper Stopping Name,Haiard Class,ID Numbor, - 10.Comallrom 11.Tocol 12 Unit
<br /> HM and PoOing Group(If ally)) No. Type Quantity INt Nal 13 Waste Cotlae
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<br /> 115. GENERATOR'StOFFERORISDERTIFICATIONt Ihereby da;am that the contRRM of this annRlggmemara dilly and accurately daecmbed,ebove by the picperchlpping name,a%I are claselfmd,peckeged,
<br /> mat rkad and labeledlpfacartled,and are In all mspool In proper condldon for transport ecmrdq to applicable intsmatlonsiand national govommembil mquladona If"Pon Shipment and I am the Prhn try
<br /> Exporter;I oarilry(hal the contants or We conNgnmem con"to mr,lomre of the otmchod EPAAckn*Bdgmont Of Cement,
<br /> I wrtliy Ihafthe waste minimintfon stommont Identliled in 4)CFR 2B227(a)(If I am a large quantity generafbr)or h)(Irl am'9 Small quenthy,generator)Is tivo.
<br /> I:iahaebrR/oPmora PrintEd/ryped Noma Signature Month Day Year
<br /> J' 16,Intemallonal Shipments
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<br /> Impottto U.S. GExpod tram9.S,)` Pon of onny/oxlt: -
<br /> imnsporter elgrmturo(for exports only): Date leaving U.S,:
<br /> C 17.TmoapchcrAckno'Madgmam o'Receipt dMetedms +y
<br /> 17,ranspOltar1 Prlmedmp�sJO,No{p(!e 9lprreJJluron j B' -p7—- _ Month Day Year
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<br /> Z ;Transporter 2 Pdnled/Typsd Name slgrbo um Month Day Year
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<br /> '48.Dlamapancy -
<br /> 16z,D19crepencyIndication.Space 0.Quantity © I_.I Resldlro
<br /> TYPa LI Partial RelecMon ❑Full Rejection
<br /> MonRest Rehlmnca Number,
<br /> 18b.Ntsfiete Fadllly(or Generator) "" U.S.EPA ID Number
<br /> Fac.3lgnPhcBiry'S one: _
<br /> 16aturo mtem
<br /> Alate FgCfllly(or Generator) - - - Month Day Year
<br /> m19.Hexardous Waste Report Management Method Codes(I.e.,cedes for hrsorcous waste heatmem,disposal,and recycling eyetems)
<br /> 2. 3. A..
<br /> � 20.beslpnafed Fadlly Dturdt or Opentar;Corfifiestlon of reralpl o(hazamooa mefarnls covered by Iho mantes!ezcepl asrided:7d Item iBx
<br /> F`ramMIryped Name Sillnalare Month Day Yaw
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<br /> # EPA Form 6700.22(Rev,3-05) Previous editions ere obsolete. - P GENERATOR'S INITIAL COPY
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