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Please orint or Was. (Form deslaned for use on elite (12-olichll Form Approved. OMB No. 2050-0039 <br />UNIFORM HAZARDOUS <br />or ID umber ((1�� /� <br />CAD <br />2. Page 1 of <br />3.,Emergency Res(po�rrk�e Phone <br />(6� 4C.�..r.3�1 ' <br />4 Manifest Tracking Number <br />000894501 FL.E <br />WASTE MANIFEST <br />04 <br />5. erators Name and Malting Address ys Sitdress(if dferentthan mailin�xaddress <br />�O %4 11 r�ggbr4 AliC��'l9c) Jan, oczc�usar("f? ello1d WZIC <br />f{fyrj�j� ��j 7G5o�Rjr�d9eSI-�x..iict k.fot� <br />�jr,, ��.,// <br />Generalafs�fkl6T2. la,J '111- '- Qu"! Ll( - 3C(P(A <br />6. Trdatpotte�npany, a rils .Hero r en ^ '!n US. EPA IQ <br />I J <br />7. Tr(a`os10•oI er C nyl�N,a^ <br />- U.S. EPA ID Number <br />6es' nated Facilip�{�a-me aj9ad� eAddress U. <br />Clean �Iur B Eng ranrmEnta.i x1�v ce <br />30ri Amerlca:n Circle \ <br />El0or�do Ar '71730 (870) 64,j-7173 <br />Facility's P one: <br />9a. <br />HM <br />9b. U.S. DOT Description (including Proper Shipping—Name, Hazard Class, ID Number, <br />and Pecking Group (if any)) <br />10. Containers <br />11, Total <br />Quantity <br />12. Uni( <br />Wt.Nol. <br />13. Waste Codes <br />No. <br />Type <br />Arnma e 1 d�3,11.d.3. (7hirf`tlerS, I�hraleuln <br />�,S �Ilafes�HFlwt1 L+n rift P61I <br />'bF <br />j <br />h! <br />a <br />— <br />RI)P61 <br />er :la PF i+ 14 t <br />�� <br />Zi lAn�niabl�S�Itdsv an1c.40,0%. &-sins <br />!�J <br />�tlh lV s( HH W), 14. OQS, egg 1aa) <br />dl <br />1 7�f0 <br />�2Q F}�nllttal3lB f u 4vx1C„r1 oS1Pyr�iAS, <br />_._ <br />X <br />�` orkr,C/l�rwJ (G./)CI/?/ ., A�aIF (erg: i3J} <br />pr c�4�a <br />U1 <br />U-QIOU <br />" Ur✓'clY� /� uXJS,ct�y�n,c,/lus;�?I'1PXC+�/�7G.too <br />7iK ��1 .}� UlJ 3 �c7, O6 t! (Prr�:tSH `PGCM�+tAG <br />1 O <br />of qqo <br />14.$pegiar ndliny Insyuctions and Additional) n1,alion` ,{� <br />bFx as <br />' o' — k C / r <br />CO;f1�a�f7tX e.F <br />.C/lz��rs6 (�n1�5irN) 7/p%/e e`/5d/xTS- <br />15. GENERATOR'SlOFFEROR'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 Iabeledrplacanded, 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 <br />- Exporter, I certify that the contents of this consignment conform to the terns of the attached EPA Acknowledgment of Consent. „ <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (If I am a large quandry generator) or (b) (If I am a small quantity generator) is We. <br />e eratoYs OReroes PrIned[Typed Name ) igna ureon ay ear <br />I .Amml Il.u�u� r ' <br />F <br />16. International Shipments' <br />❑ Import to U.S. ❑ Export from U.S. Port of entiylewe <br />Trinspurter signature for exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />af <br />Transporter 1 Printed <br />(; +ad Name ignature/ ey ee�arr <br />a! <br />f`,I"J <br />Z <br />Trans r 2 Pnn dIT tl Name Signa - Month ay Year <br />%. It L-1, <br />e/ 4 <br />18. Discrepancy <br />18A. Discrepancy Indication Space. QuanBly ❑ Type ❑ Partial Rejection <br />❑Residue I ❑Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />a <br />�- <br />Facility's Phone: <br />18c. Signature ofAllemate Facility(or Generator) - Month Day Year <br />Z <br />19. HazaMoueWaste R port Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />4. <br />A <br />Q� u <br />2. 3. <br />-(LTJ- nL(O <br />20. Dwignate4 Fealty Owner of Operator: Certificated of rpt of h Mous materials covered by the manifest ez t as ted In Item 18a <br />Pdnted7ryped ame <br />/ Sign Dai -Aar <br />6 <br />/A 111 <br />EPA <br />Form 87 ( x3-05) Previous editions are obsolete. <br />nPRIrIJATFnFArII [TV m6olJPReTr1R <br />