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Please pnN or type (Formdesigned for use on elde(121Ach).typtninder.) .. Form Approved.OMB No-;20-504W9 <br /> UNIFORM HAZARDOUS..•,4:G6c*3torlDM#WW` 2Pageld 3:Emegemy Response tNrwre /Manndfes�t T�rz]el'dpn9,Mum6er - <br /> W,ASTEMANIFEST1. 5{I j/) °Pl Plane <br /> ?fist' y'o1 G:.{ k5,7 9 5 8 FLE <br /> :6 Geneim's Nameand MaAoigAddiess ..:, - G+nmatWsS Pdd'ess(ddiduaent Man rtwTmg address) <br /> r_<rc y P:3tf ii ,F� kiik4l L+.FIi 3t 1{t ES Il' iF, t'iaMU ft-ll 10"A4 RIITOIkAi <br /> tSts Eiia1 EffiItFCit�tY'?A� t�3 p.ia. ��t�sn3F tYff <br /> Gviereb.Vf `.041 N 4� Yt t. AN-k "i,ah - :i3E+.kir bH.a'`a °a <br /> I-M—n—sp-ORPTCompanyNam . -. - _._. „ _.. U:S PPAIONWTbff. <br /> 0-,W(UPY tS9uLPN4t1FHWL tfittttit,r;q(;iF -fit ?7F.VlS?ti, LL ` AR(_fi1tl.;iPl4:ff1:,' <br /> -.7rmnspoder2Conpary'Name.. - _. _.. .. U.S.EPAIO Number <br /> &DeWgreted Paddy Name and ShAdisess U.S.FPA ID Number <br /> fag sPhare: 1b'E.t�. EI: fl' i.l y •' <br /> ga, Bb.U.S.dOT Description(inducing Proper Shpyirrg Name,Hazaid Clan,ID Number, 10:Confiners 11.Toll 12.Unk 13.Wash Codes <br /> NM and'PatlaM GouD(0 any)) Na - Typo G2ntity,.. . WtNd:.. <br /> a t <br /> 2. <br /> 4 <br /> 14 Spedal HaM,ngla5 diomaMAddhonallnformatron - <br /> fd+ §rr'38AdK?4-zo [bt.i 3cli ?r;p (kf�( #:?�lN,!`. t4 f. IF+ f ,'t t..Y,ft'( ':+sSeh ei!••ri..3 f�r_sidis7li> Yr...e. .x :fir:1.,;c;.:a.. i <br /> ti <br /> 15 GENERATOR SIOFFEROR'SCERTIFICATI.ON:-l hereby declare mntentsoffiis,mndgnmentare fully and accuraoly desrnUed above by the propersh(pping nams,erdae dassifred,packaged, <br /> marked aind IabeladfptacaNed,and are in all respects in pmperoa bitipl far tianrymfacorni ng to appllratilefnlertg8onal and national goverrmtevpal regulations.H inpi ehiprnerit and l am the Primary <br /> Ezlxxte0l mrMy that it*antents of this consignment conform to the term of the atladled FPAAden Wed9mentofC 5.1... <br /> IIAcerh{fyfthat thev,Jamste minimization statement identified in 40 CFR 26U7(a)(it l ama large quaintly gellenata)or(bf,Cdtav,135reall quantity gancratorj"a vueMorith year <br /> )fit <br /> f•F>•3f+'Y.. sl'•,+1, f(.,�.4'.h..,,..04 p h.. P 4 9�'� § 'G� A t ! ✓ f k.✓r. <br /> J 16.Interna"Sfpmets - - <br /> i- ❑Impodto U.S ❑bwdfiom U.S. Part afentryledC <br /> Trarriponerd hse for eWgts only): Date leaving U.S.: 1 <br /> WWK 17 T "btlnraMtd§m'wdotR2 ptafMateriels ._. l <br /> _....__. . . .: <br /> Tanspoder PdntetllTyped Name.. _. - _. . Signatare. . Mwth Y year <br /> Q <br /> -4T - -t <br /> u <br /> mrWwleI Artea7fylod Neme'. Wre. _ p ear <br /> t18 Drsoepaney. - <br /> � 18a.Disc eon y lod'6segr Spare ❑ Ouanhty. ❑Type ❑Residue ❑Partial Refection ❑NO Refeeaorn t <br /> Manifest Reference Numb <br /> 1Wr Alternate Fanldy(a Generator): ... . . U.S.EPA ID Number _ <br /> U - <br /> LL.Faaf s Phone: . _ <br /> W..Signature,ofAhemate Fadiy'(or Generator) _.: _. Mo m. Day year <br /> Q <br /> Y <br /> H 19.Hazardous Waste Report Management Mettiod Codes(e.,codes for haz is a Ieitmdrnanh disposal.and mgding systems)' - <br /> C 1 12. .:_ i 4. '. <br /> 20.Designated Fealty C+ era Operator Cedfirationof receipt ofha>ardous materials memo by ft wrofestexrapt as noted In Item_Ise <br /> PnnleCyped Name Signature Monts De, Year <br /> 1 <br /> EPA Fotm&100-22(Rev.M) Previous edhons are obsolete. GENERATOR'S INMAL COPY <br />