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09/24/2014 10:37 2093344684 #6346 P.003 /003 <br /> Tease print or type.(Forst desiqne4 for use o i elite typewriter.) Fon Approved,0148 l'lo,205W39 <br /> 1 <br /> UNIFOFW HAZARDOUS 1.G-enerator t)Humber 2.Page I of 3.ErneWncy ReWse Phc --14-—Atmgm <br /> WASTE MANIFEST 4AlAXKLWj3"3 47 3 12 . G-BF <br /> T"G,-mvoesNeste azul M*&Tg Address <br /> Ih <br /> 62 3E Vil."I ou RiD, RECE117EIY <br /> L.f CA, 9 S?4 0 <br /> C-emraws Phone: <br /> 6.Tr.ansower i Company Name V.S.EPkiD Nmft <br /> NVER I AN VAI Y.r Y <br /> 7.Twspo"2 Company Name <br /> ENVIRONMENTA HEAfflWU7----* <br /> 8 D-VAW Pwity Name and Site Address DEPABMENT <br /> 2157 a-10 UR Y!F.KVtK*WXYAt MGM f<0 HUVAJ+y,(J,C Q S.EPA ID Ni-m�— <br /> Ata};r.tR <br /> -Fadlitys Phone: <br /> ga. 9L U.S.DOT DeXr0on(including Pmper Shipping Name,Hazard�,3 .;D-Numbe, -low 1z.unit <br /> HM 2nd Pacl;ing Group(I any)) 3.WaVe C>d% <br /> :No. pe Coaroty vvtAo, <br /> R4)NA.V"'L6C,rAR")()j,;',VVA1-'Jr,- T-4 r)S 1} <br /> P <br /> z <br /> 3. <br /> 4. <br /> I'f.Special Ha"1nMxtbns MO Affition'sh—tbrMhon <br /> PRO FiL L#(ijj�-7 a L"004E 4 ZAE L. .0,* ( iL 1 t:R!i-t�)�A.s 6 1 ct% t.ow�jy mm Ltits <br /> APi4t04:1�WrE Pkt>ffC11%1�CLQ 4 filfw'� <br /> $F-E ERG At 01A <br /> 15. GENFRATOR'SK*TERMSCERTIFIC)TOM! I hereby derAve that I&,contents of thi$0onsirdw,are fUty and Occura(14 de-Salbe I above by the jxooer shipping name.0'are dauW-ju*6*, <br /> marked am labuieftiBcardW.8M are in i iF,resip6ct ifi pmpef 00n(JitiOft V transport accof&g to applable kTtemahonai and national gvetwWw regWat&s.N export shipment and I am'ft Pi maity <br /> Exporter,I certify M the contents of this 0 m4nment conform to the W=of the amdW EPA AdmOW4*nen t of Consent <br /> f GerffYthat the w2SW min lien=ternmtkleniffed in4OOFR 2$2.27(a)(0 lame large quMfitygetteetor)Dr(b)(if I am a smaN aerator)is true. <br /> G;70,-,e-V0&-e8—Pdlledqypd N.-a SnaOrre <br /> qwrtlo Yw ' <br /> Impott 10 U.S. E-j Export from 1j.$ Rom <br /> Transporter 6001we(for exports Only) Date.leaving U.S.: <br /> 17.Transq6ft Aduvaleckjrwt of Reo <br /> uj <br /> Tran 1 <br /> CI r smote, morm Dy Year <br /> 0 <br /> L <br /> I WsPorw z Priv WTypad New, { Bigots <br /> morwill) fx� yek <br /> 18.Dcrepancy <br /> Ise.D*M;pancy Indk2hon space ❑ Q antity El Type 0 Rebidue El partial Reje0j4n 11.ktllje,I ion <br /> Nlonif"RelefW�ce Numb?r. <br /> U.S.EPA 10 Non-Aw <br /> L'6 Facility's Phone: <br /> W turk.of TU�Pacft Facility(or <br /> !R I kmbo Y <br /> D y ear <br /> z <br /> 0 <br /> 19.Hazardous Waste Report Managwrient Cocks h..,dous waste <br /> treatment,disposal.and mycft system*) <br /> 2. T 3. -4 <br /> 20... Facitky Owner or 0W&W.0MI ztion of receipt of hazardous mftrials ooveW ft by manifestexceptis noted in item 18a t <br /> pl� ff Signatt7im Month yar <br /> -05) Previous ed <br /> EPA Form 87Z22(Rev.3 <br /> t�bsoie . <br />