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r <br /> Please print or type.(Form designed for use on allte(12-plirh)typewriter.) Form Approved.OM®No.2050-0099 <br /> { UNIFORM KAZARDOUs t,Generator ID Number 2.Page 101 13.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C" 3 Jam' f�{ 1 c tet ' �' �.�= 7 r .5� X10 1 J <br /> S.Genersior°s Name and Mailing AddressSfre� <br /> Gene 's Site Address(it diffewi ten mailing address) <br /> 'IFt,n•t '/,/fC,c• <br /> Generator's Phone a'.'-1'-1e4- !s%�1.—S <br /> 6.Tra7orer i Company Name U.S.EPA ID Number <br /> � „ .� .rte' , �s >-, c: .�; v se:,r ciii' <br /> 7.Transporter 2 C&Mpany Name U.S,EPA ID Number <br /> S.Deslgreled Fadlhy Name and SlieAddreuU.S.EPA ID Number r.rLL /fit GYM rcl 'Cj� :✓,f F <br /> 0 <br /> Fadi 's Phan /Jti Cf 32 C-3 wl- 4(--)6•ii0 2-I 5, <br /> go, gb.U.S DOT Desorption(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit 13,Waste Codes <br /> HM and Packing Grasp(d any)) No. Type Quantity Wt Not. <br /> ® 1 s�/.>�.% ��:�K� f � Ler 7: ��<• le.�-•'. trt�r�?�� �,;�lG• ��,•� ,Qat-.�••.� <br /> z 2. <br /> W <br /> C7 <br /> Fhis rub t; You' <br /> 3. CERTIFi;,ATF <br /> OF RECYC'UNG <br /> 4. Date. <br /> 14,Spies claT Handl g In7ollons and Addldoml Information <br /> �+ l7 <br /> , <br /> 1 P <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare(hat the wments of this consignmW we fully and aoiximely described above by the proper shipping name,and are classified,packaged, <br /> marked and labeleftlacarded,and are In all respects In proper condldon for tramport according to applicable international and national govemmenlal regulations.If export shipment and I am the Primary <br /> Exporter,I certify that(he contents of this consignment conform to Ue terms of the attached EPAAckrnowledgment of Consent, <br /> I rartify Ural the weate minlmhsdon ataterrreni IdemtAed In AO CFR 262.27(s)(d 1 am s large quamlty genrarator)or(b)(if[sm a small quantity generator)la lire. . <br /> GerneratorsrCflrera's Pnr(fedgyped Namq Signature •, �' Monith )Day Year <br /> -+ 16.International Shipments <br /> ❑ImpoiR to U.S. ❑Export Fran U S. Pat of enkylexit <br /> Transporter signature(fa experts only): Date wing U.S.; <br /> 17.Transporter AdmWedgment of Recelpl of Materials <br /> Transporlar 1 PrinWiTyped Nararae f:' �f f/ Signature ,.r n�i Day Year <br /> ac Trpnaperter 4Anlecl fyped Name $Onet{Its Month Day Year <br /> 16,Discrnapancy / <br /> 1 Ba.Discrepancy Indimtion Space ❑ Quantity ❑type ❑P.Wdue ❑Penleh Naodar ❑Full Raledian <br /> Manifest Reference Number; <br /> 19b,Ahemate Facility(or Generator) U.S.EPA ID Number <br /> v <br /> es ` <br /> W Faalily's Phoria: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Menagemitimr Method Codes(I,e„codes for hazardous waste Treatment,disposal,and recycling systems) <br /> ® 1. 2 3. 14. <br /> 20,Designated Facility Owner or Operator CarNflcation of rept of hazard materials covered by the manllesl e p s1r n Ire <br /> Pnnffyped Name Month Day Year <br /> v-- 'U <br /> EPA Form 87 22(Rev. ) Previous kions are obsolete. DESIGNATED AGILITY TO GENERATOR <br /> 800/ZOOq3j 1383IGIS b11999vG0Z )(t!3 130:Z1 ZOOZ/tri/40 <br />