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Iii <br />F. <br />AIL <br />Form Approved. OMB No. 2050-00399 <br />d [muse on egte (12 itch I owdterj <br />Please -p <br />print a type. IForm dselene yp <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page t of <br />3, Emergencyfiesper <br />-." <br />4.Mamfesl TrasNil(p�N.u(mb/e�rooC DAT <br />OO O O 6 Z 4 6 <br />WASTEMANIFEST .-. '.( .':.'' <br />.. <br />G <br />5. Ganazalas Nance 8" Matileg Address Gena,etol'e 9,c Address I'f ddlararA nFr, ma hro addrassj <br />L.., <br />G6. eTnmanrhC <br />mparry Name U.S. EPA ID Number <br />7. Tcrospomr2 Company Name US, EPA ID Number <br />8. Deelgaatad Fad'.ily Name ar3 Site Address US. EPAID Nammr <br />Facsil sphere <br />ge. <br />he US, DOT Descrip0on(Indudrat PmFe+ShiplerV Name, Hazard Class, ID Number, <br />10, Container <br />11.1otal <br />12. Unit <br />13. Waste Ceras <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quaintly <br />Wt N01. <br />II <br />o <br />Zyba <br />- <br />a <br />` <br />q, <br />14. Special Hand: nc lrLlwclima oral AC61 anal Inlormalim <br />15. GENERATOR'SIOFFEROR'SCERTIFICATION: fhereby declare that the contents ofthis consignment are Poly and accurately described above by the properShlpping name, and are classified, packaged, <br />marked aro IabeMplemrded, and am in all respects In proper mndilion for transport according to applicable htemsdibe l and national govemmental regulations. If exportshlpment and I am the Primary <br />Exporter, I rarely that Ina mnlents of [his mnsignmenteonfmm to the tams of the attached EPAMmowledgmenl of Consent. <br />1 wmfy that the waste m nimealon statement identtrsd in 40 CFR 262.27(a) (t I am a large quantity generator) a (b) (ill am a small quantity generator) is Wa <br />Gotoe 0115mr ntWyped Nam S <br />M <br />to into Y <br />�J <br />16. International Shipmen ImPad b U.S. LJ Expect from U.S. Poloteny1ex11: _ <br />Transporter signature (for exports only): Dale leasing U.S,: <br />1 pertorAdmowledgnrhmtofRecelp[of Materials <br />T spagaer 1 Printed/lY ad re nth Day Year <br />a <br />i <br />Tfshispasterg Pdnted/fyped Name SignaWre Marie Day Year <br />18. Discrepancy <br />I <br />18a. Dkriepancy Indication Spam ❑ Quantity❑Type ❑Residue ❑ Partial Relcolion Dar Room <br />Ntxrdest Reference Number, <br />18b.Ahermale Facility for Generator) U.S. EPA IO Numiner <br />V <br />LL <br />Pham: <br />FaoYilys <br />18c. SNUIM"l Alternate Facility (9 Gere2br) hionm Day Year <br />aW <br />2 <br />1B. Hezandous Waste Report Management Method Cod" (Le., codes for hazardous waste trammant, disposal, and recycling systems) <br />C1 2. 3 4. <br />7 � � <br />20. ,noted Fadlity Owner or Operator: Certification of receipt of hazardous materials covemd by the manifest except as road in Item IBe <br />Il PdnleMypeciNang Signal, hlenth Day eef <br />V1 <br />EPA Form 0700-22(Rev.3-05) Pandouareditters aro obsolete. DESIGNATE ACILITY TO DESTINATION STATE (IF REQUIRED) <br />