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Form Approved OMB No.2050-0039 writer.) 4.Manlhst rackln9 Number SKS Please poor or type (Form destgred for use on elite(12-pitch)type 2 Pie 1 of 7.Emwgency Rosponse Phu 5 5 LEI UNIFORM HAZARDOUS t Generator ID Number 7932 ailing address) WASTE MANIFEST Generators Site Address(d ddferent than m 5 Generators Name ana Miring Address �); FPA ID Number Generators Phone 6 TranspoRer 1 Company Name I _ �t U_, EPA ID Nurob9tI ,)L- f -•jrF 7 Transporter 2 Company Name LU i i ,l(1 i U'I'S ID Number 8 Despnated Facility Name and Site Address Faolil Phone 10.Containers 11 Total tWaste Codes ga 9b U S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, No Type Quantity HM and Patting Group(d any))NC N-IRC;RA 4AZAF. - LIGU C0 o (AGUELOUS PARTS ii�F9rlEft ;u�UTZUN? 7W t— w � z U.1 c7 3 4. 14 Special Handling Instructions and Additional information r OR E.11%kGLf4 i H �7vU...� .:.- :i: •i'ir c+ 'i—i�: ,-rsl AS "ArFNT -FOR" PY (3FN TO RETAIN I.ZCENSEi 15 GE NEFtATOR'SIOF FEROR SCERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. GeneralorsirOfterbfs Printed/Typed Name Sigpature Month Day fear rJ 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entrylexit: z Transporter signature(for exports only): Date leaving U.S.: w 17.TransporterAcknowleelgment of Receipt of Materials Transporter 7 Printedff ped Name Signature Month Da Year a S.:70/VC`0 4c t_ .4 e Z Transporter 2 Printed/i me Signature Month Day Year 18,Discrepancy 18a.Discrepancy Indication Space ❑ Quantity Type Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone. I w 18c Signature of Alternate Facility(or Generator) Month Day Year t— Q Z Nji 19.Hazardous Waste Report Management Method Codes(i e.,codes for hazardous waste treatment.disposal,and recycling systems) o i 2. 3. 4 20 Designated Facility towner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pnued/Typed—Na" - 5lgnature Month Day Year EPA FortTt 87 .-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACIILITY TO GENERATOR