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Please print of type.(Form designed for use on elite(12-pft)499MW.) Form Approved.e-U(7,%,-.N50-0039 <br /> 1.Generator ID Nuot*r r, 2.Page I of ErM Tracking Nu mbar '�­7 1- <br /> 3091.3 - -P p!.Iq 4.MLnhst -7 FLE <br /> UNIFORM HAZARDOUS1 -25Y56", 42 <br /> WASTE MANIFEST UO3 G <br /> 5.Generator's Name and Mailing Address Generator's She Address(ff different than mailing address) <br /> "M <br /> f 5L;if? <br /> W11 Rill <br /> -rip <br /> CA 9521151 <br /> Generators Phone: <br /> 6-1raruporter mDany <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S. <br /> EPA LD Number <br /> B.Designated Facility Name and Site Address SPF;::TY--KLZfiN SYSTEM85 INC. U:$,fE"D Number <br /> fl w21 11,100PEF <br /> DEN 1-16208 <br /> T.,O)OP'N50 137 1 <br /> Fact't Is Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Wasta Codes <br /> HM and Packing Group(h any)) NO. Type Quantity WLMI. <br /> DIM P Doe,I <br /> 0 4. <br /> 'it A"T <br /> C7 <br /> 2. <br /> LU <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions;and Additional Information SK SHIPM&2*397W I 42935 C G <br /> 'f? <br /> "i TIC. J"Ir" G1jTi1-'P1jV.mT 41411,AI&II.ALL=9.R539`4 <br /> 15. GENERXtOn10FFER#S CERI'llIFICATION: I hereby declare that the contents of this conilgnment are hilly and aoctiplely described'above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are In all respects in proper condition for transport according to applicable International and national governmental regulations.ffaxport shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I oe"that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. -------ll Day Year <br /> Genprator'-dOfferoes inyped a <br /> Prtad/TNm nes re <br /> sigtu <br /> + <br /> . I - ( - -1 1 <br /> -j 16.International Shipments <br /> ElImpod to U.S. El Export from U.S. Pokofentrylexit. <br /> Transporter signature for exports only): _Date leavmg U.S.: <br /> LW 17.Transporier AcIlknowledgment of Receipt of Materials <br /> Transo der 1 Prinl Name <br /> Signature on Day ear <br /> 'P <br /> CIL <br /> 00 <br /> Z Transporter 2 Printed7yped Name Signature or fear. <br /> 19.Discrepancy <br /> 18a.Discrepancy Indication Space Ll Quantity El Type Residue 0 Prtial Rejection El Full Rejection <br /> Mandest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> L6 Facility's Phone: <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recyding systems) <br /> LU i <br /> G 1 2. -T- --T <br /> 20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in ftern 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form.870.Q-22(Rev.3,05) Pr ious editions are obsolete. GENERATOR'S INITIAL COPY <br />