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se � / use stttihii3 (i2�cA1 <br />{ <br />1. Generat<v ID Number <br />•7 ., .�_ ,. ,: � - . .::. - _. .., ^ . - ... . <br />2 page 1 or 3. E^e?ueru7Resa Ph0ae 4, Manifest Tracking Ntanbet <br />spona <br />q (�U <br />j jK <br />UNIFGRM kZARDOUS <br />Z `t <br />012177674 <br />- . 2 i 7 7 <br />WASTE MANIFEST t dfl(7 �.: <br />S.Gener�tor•std�ama� Ihr1llY�IfLtkC. M''TN Ig� <br />Gerterz:n+'S Site P.dd'ess !if diffetern tion rnarlir.^ at3drdres5i <br />-'0�� T <br />Gene-ator's PfNme: —7 <br />U.S EPA ID Numf>er <br />6; TranSpotler 1, Company N2me <br />7 1,aj%sPofte-' 2viT.pafi ka-^u <br />U.S. EPA 0Num;,er <br />S Designated Fa.:iP. Y tiarw and S te.4ddresse .w r <br />e , 1 e —J U.S. EPA ID Number <br />K <br />C'` -r/ CIA 113a39 614117 <br />Om <br />; acs. v's Pt cne:ft Pul-allm <br />gz, gu. U.S- DG T Desuipbat (ul mg Proper Shipping Name, <br />Hazard Class, ID Ni•mber <br />1A Conta ners <br />t 1. Total <br />12. Unit <br />11 waste Codes - <br />No. <br />Type <br />HM and Packing Group Cit any), <br />Quantity <br />VA ivbl. <br />�o>v, OR GAA AAACIVS WA4r:e,tf,6-,a <br />t of Cy '5011n5 <br />Oo i <br />t <br />l <br />rim <br />14. Spectai Handling ins"n"u and AddPAra urrmaI <br />aAI) 64 6 <br />CA <br />i <br />�2vAllrpt <br />31A) <br />:5. GENERATOR'SIOFFEROR'S CERTIFICATION: thereby <br />ledarethat Oe contents of Vus consignment are tufty and accuratety described above by the proper shipping name, and are classified, packaged, <br />mati,ed and tabe*loa-mrued. and we r all respects in pr <br />e: condllon for transport axxdirg :o apphcabte irdernaticrtai and national governmental regulations. if export shipment and I am the Primary <br />Erx ner. ! certify that the contents of this !xnsi4nmenl con <br />arni_iothe :erns of Cie a: ---ached EPAA.Kno ;--dgment of Consent <br />certify that the naste m r urn ai 7n staieawm idenhf'e" n <br />d(1 CFR 26227(a) ;if i am a !atge quantity genera" or (b; (if I am a skA quanbty generator) is tnie. <br />Generet6r' rofsPrintedTyped.Name <br />Sgnature Month day Ygar <br />) <br />It,2 <br />f� E�r C1 �4 <br />_ <br />i - a <br />�3 � 7 <br />" <br />F- <br />16: lydemabonal Ship is �' <br />- - ] impod to U.S. 'EJ Export trim U. S on of entrylexd: - <br />Transporter s!9nahlre (for exports orvy Date leaving U.S.: - <br />W <br />U <br />17. Transporter Ari novredgmeru of Receipt of Matenals <br />- <br />� <br />Trots er Pr r ted�Typ. Name S a Month : fray Year <br />CL <br />Z <br />Traj ispTrio 2 PnMedl ypo Name *nature Monthy <br />da Year <br />f- <br />18. Discrepancy <br />&a. Dos repan y Indication Spay ❑ Guanury <br />Ll Type E 1 <br />LJ Residue ❑ Parliat Rejection � <br />Full Rejection <br />Man fest Retererroe Number. <br />15b. Afternate FaUiRy \7r GenBratorj <br />- <br />U.S. EPA!D Number _. <br />J <br />U <br />FadtiwsPnone <br />- <br />W <br />1&. Signature of Atterrote Facility (or GeaeraVw <br />ZMom <br />Day Year <br />y19. <br />lbr liazardlus waste Ire*WT71 disposal, and recy" sysbems) <br />Nazardous Waste Report Managenwtt Method Crudes (I.e., <br />O <br />2. <br />4 <br />20. Designated Fad;tr Owner. orOp�rato Ce�ion of recmrl <br />of nazafamA materiafs covered byte manifest alt" as nmad in Item, ia,, <br />Dr,,11;c�;T�� �2tif� <br />r SigrtaUirs � , <br />� <br />.x. Month Yew <br />-PA <br />Farm E70 -22 (Rev.'MS) Pr9vtous edjtiortS ale ODSotet <br />. [) �l��fdAT):tS ACiL1TY 70 DESTU3t rnu �� ,.� _•_ _ <br />.....�,H� m tit- r3ita�lJiREDj� <br />