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Please Print or type. (Form desinned for use on elite I12-oitch) tvnewriter t <br />c,,,.., e..,.......,n nlr0 Nr. 'ar141. pro <br />DESIGNAI ED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />1 of 7. Emergency Respohse Prone 4. 000358838 t TnickIng Nutt <br />UNIFORM HAZARDOUS 12. Page CQJ <br />WASTE MANIFESTa MA F L E <br />5 ralors Name end Mea'vg A4101rasiS Gererala's Address rf ofi t Nan maAep asook ) <br />Co K1Mb(� RrT�(c'�JS tln o Household Aste. <br />i$kOloaguIn it Li <br />Wkz,ek1 on F0.C11,��I <br />Ga Kk on Cq R5do1 '1�5G s (iA 13r;dtekrd Si 4orz�fdnCA <br />1.7 a any aoa U.S EPA n CO <br />ID NumAer <br />I n -, <br />7. Transponor 2 Company Nance US EPA ID Number <br />8 Designalea Facility Name and Se Addrass US EPA ID Number <br />C1e ra 1Ackctor5 EnQkronmenktl <br />?fix{ AmerlCQn Citl <br />n � <br />Farah es Pl rmar - 3' <br />ga <br />HM <br />91,. U.S. DOT Desaipti (,naudug Proper Sbippeg Name. HazaN Gass. 10 Numbs. <br />and Packing Group (if any)) <br />10. Cmlainars <br />11. Total <br />12. Unit <br />11 Waste Lades <br />No. <br />Type <br />h <br />VAAV <br />rya_ <br />a <br />` larml IIgUId, r140C!-.,.,�h,nne(-5 <br />-61TX <br />�e4roleumijls+ll1Gk�cbCrf4w)),3;un14G3jG11 <br />Oi5 <br />0490 <br />— <br />twin <br />w <br />2. fn {^ QeIa+Ld ftierIal'(10arniTh, nner0.1Oas af <br />0.1I*(�" V') 3,Un IQ -(.A )7Ga CDor-SP- Illody� <br />l7 <br />11 <br />�F <br />— <br />V <br />v <br />a. I qtr <br />r <br />' <br />N <br />f^10rfi�j,vC' Ilz"�1y��-�dlbaSiC.,Inor nr(�rr�.p,/����uam <br />uyClrci.rC1C,i�c+rfihilramN droy,IdG <br />L.In 3A.rC4; PC>j[' <br />Ic. SpeWl Hasal instructions a, AddNonal Information <br />1 •� CN�4���t1 15 x 65 -him YW 4-. I x 671-111 ItCH)—C4 3G)JAI <br />a.� CH1yClUa5 Eo ; � 1r,xvnbe_ F JV A0000t <br />"T' -1(0 <br />II ZJZ 4 <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare Nat Ne cont,,S of Ws conmgnmanl am Ivry and accruably desalted above by the Proper aMppng name, and are classified. packaged, <br />marked aro iabeledQYecamed. and are in all respects N proper cdridi{pn for aanspod according b aPPhl inlemational <br />and nationalvernmenlai regulations d ex <br />9° 9m port shrpmpnl and I am the Primary <br />FapodeF I ceNry Nal Ne contemn d Itis mlaigmrrenl oaniam to the lama of the attached EPAAricnwdedgment of Cmaent. <br />I rrl8fy that u e waste matunizalbn satement identAred in aP CFR 262.27(a) bf I am a large quentl y geruaator) a (b) (if I am a small quznary generator) is me <br />rator emes nt yped ame stgnature Day Year <br />I u E*1 <br />16. Intemaiional Shiprwis <br />EJ Import to U.S. ❑ ExpM horn U.S. Port of entryleut. <br />Trarmflwlirr signature bre Date leaving US. <br />W <br />17. TrenspaterPclmoslMgranl of Receipt of www, <br />O <br />Tnanspilder 1 Pnnledrryped Name myaute <br />a� eat <br />.C�y"r•��^�'�i i1 . <br />, I ` ' <br />Q <br />Trenapprler2 PnnledRyped Name gnabre N Year <br />ay ear <br />} <br />18. Discrepancy <br />18a. Disael odicalion Space ❑ QuanGN ❑ Type ❑Residue El Partial Re)eaion F0 Full Re lion <br />Manifest Reference Number <br />tab. Ailemate Fadldy (a Generalm) u.5 EPA 10 nmmber <br />U <br />LL <br />Fa " s Plane. <br />18c elgneare ofM mate Facility (a Generahr) <br />Z <br />Menti pay Year <br />19. Hazardous Waste Repod Management Me bod Cade, (i.e.. fa hazardous <br />code, waste aeabirwt disposal, and reryctirg systems) <br />1. 2. <br />0 <br />7. 4 <br />1 <br />20 Designated Facility Owner a oPeraatr: Cadit an of recegt d tazardws materials covered by OrePratedlTma a es axcep a5 ro ed in Item 18a <br />YDed Name Slgnalure Monty Dry Year <br />EPA Form <br />87M22 (Rev V51 Pravums viiiii are ntxdefn ___. _.. __... <br />DESIGNAI ED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />