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it' <br />Form Aooroved. OMB No. 2050-0030 <br />Please <br />print of type. (Form designed for use on elite (12-pRcn) lype'anler.) <br />2. Pagotof 3.EmergaI ) Re sponse P'nore 4.Maniresl Tracking Numbar <br />UNIFORM HAZARDOUS I. Generator ID Number <br />000051553 DAT <br />WASTE MANIFEST ..,,, ,.,, f, C.�', -,. <br />Genemlers SiMAddresa (dddferenlIban ma `ng address) <br />5. Genorato, Nzme and tta"ng P.ddnss <br />C n=a'ors Phone's —._ 'n dr r� r r'RA <br />U.S. EPA ID Number <br />0. Transporter 1 Company Name <br />,3 -ra - r•G -: + r <br />U.S. EPAID Number <br />7. Transpoder2 Company N <br />D <br />U.S. EPAID Numbar <br />8. Des'yna:ed Fz6'ly Name and Site A dress <br />Fzr:'lyi Phone: r.' . :r 4 ^ ':1 �„ 7 1 •�� rbi <br />ga, 9b. U.S. OOT De:gAplon(ndud ng Proper Sh'pp ng Nawa, Hazard Class, ID Number, 10. Contra ners 11. Total 12. Un1 10.1Yasle Codas <br />171 Not. <br />HIA and Pack;ng Groan prany)) No. Tyr- Ouenbyr <br />I'.Iin^r.) <br />12 <br />Of <br />a2. <br />F <br />- <br />4. <br />TT--1— <br />.8p,,,,IH,,dd Addt'onal Information <br />T4-- <br />ni- r n u r!�.(n'•It: tun , I Tf Is l„I r,,l II(•u!.[PI it 1�1nll nus ('Ir'•t� r(! UICf'Rt61.6u. <br />I hereby deCIAM that the contents ofth:s consignmenlare fuly and accuralefy described abava by the proper Wiring name, aMere dassifed,peckaged, <br />15. GEIIERATOR'SIOFFEROR'SCERTIFICATION1 <br />marked and labeted'p'acacded, and are in an respecm in proper conchfon for transport accord ng to app!.mb!e in!emabenaland national gwernmenlal regulations. If export sNpmenl and I am the Primary <br />Exporter. I codify that the coa!enis of th!s con gnmenlconform to the terms of the attached EPAAcknov6edgmenl of Consent. <br />identbri in 40 CFR 202,27(a) (if large quantity generalor)or(b)(ifI am asma'I quantity generator) is We. <br />I cefy that the TizaFon s!atemenl <br />rtin I,on� Day fear <br />GamnatoyslORer ys PrimedHypad Name S!gnatum <br />—r 130 1 i <br />e <br />F <br />IG.Inloma0ana Sli pmsnls ❑Impartto U.S. Export from U.S. Podolenlry;efl: <br />z <br />Twsporters'gnalure(for e>podn• only): Dela leaving U.S.: <br />W <br />17. TmnsporterAd;nns'edgmenl of Re[aglof l!aleda's Month Day Year <br />Tr' I Printeda..e rte <br />a <br />W <br />Transporter 2 Pdmedrryped Na me S!gnature ILa <br />"511 <br />b <br />t- <br />.N <br />18. Discrepancy <br />18a. Discrepancy lndicaCnn Space ❑ puanGly ❑Typo ❑Res!dua [I Pool Re;ec4on ❑Fu7 Reectan <br />ttan!esl Reference Number. <br />U.S. EPA ID Number <br />18b.Allernale FaVily (Or GenembQ <br />V <br />Fac2Il1s Firm Month Day Year <br />w 18c.S�nalure olA!temale FaG:iry (m Genero!or) <br />Q <br />z <br />N 19. Hazardous A'as!e Repodfdanagement h!elhad Codes (i.e., codes for hazardauswasle BeaMent, tlisposal,and recyd:'rg systems) <br />wo ! 2 3. 4. <br />20.Des!gnaled Facility O.meror Operator:Cediecatbnofrem1plofhazardousma!edalsw•+ered by the manifeslexce 1 tam l8a Month Day Year <br />Sig e <br />Pn ' <br />IV 6Nat <br />wto en T1NA'rinN STATE IIF R 01 1 F1 <br />EPA Form 8700-22 (Rev. 3.05) Previous em0ons are ooso:ete. 11112=:3.16..-1— <br />