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,YZI Form Approved.OMB No.2050-0039 <br /> Cie print Int or ty e.(Form designed for use on elite 12-pitch)tpPaWrIlar) <br /> 15 - nifostTracking Number <br /> us 1 1,Generator ID Number 2, go Emergency 4.Ma <br /> UNIFORM HAZARDO <br /> WAS <br /> r TE.MANIFEST 016011466 JJK--- <br /> 5.Generators Name and Mailing Address Generalo?s to than mallIng address) <br /> a nDr hlor's <br /> 6.Transporter 1 Company awe, <br /> U,8,EIWA 10 Nutnbar <br /> U.S,EPA ID Number <br /> 8.Ilesignated Fadlity Name and SltekdW' U.S.GPA ID Number <br /> AU110 . .. <br /> Pa on 9410 <br /> esoriplion(including Proper Shipping Name,Hazard Class,ID Number, 10.coatewd om 11.7blal 1Z unit <br /> Ob.U.S.DOT D ---- -- %Waste Codes <br /> Hivl and Packing Group�f any)) No, Quantity Wlivol, <br /> Wa <br /> "V-,VI <br /> LU <br /> 3. <br /> 4, <br /> 14,Bpeclaffland ng inatructfons andAdddtonaflnformaion <br /> air" '0 <br /> 97473;- <br /> GENE <br /> ORE RORISVERfIFICAT are fully And accurately,described above bythaproper shipping name,AM erqclasslfied,packaged, <br /> "8.N"-1—e'-'- -'--'- <br /> --nn eda4t - Wor, droond r <br /> p <br /> Exporter,lceflify l *111eedrildnts-bf Vils consignment conform to the terms of the pdoohed EPAftnowledgment.of Consent, <br /> I oedifythafilie.yrasle minimzetlbristatement(dent[fled In 40 CPR 262.27(a)(1(l amu large quantity generator)or(b)(Iff am a oaf]quantity fforle!ulor)Is true. <br /> npratoesiollerofs Printedframe S nRute Month Day eat <br /> X*— <br /> Ci 18-11flerflallonall shipments El import to mg. MExport fromu.s. ' ort orenlrylaxll: <br /> Date leaving U.S,; <br /> Va hspoqet signature(for expo&MIL <br /> ly,.Tr.onspoderAcknoitAodgmentofRocelplofmatedals <br /> 'rraWsporter I PrintedMped Name Monfh Day Year <br /> Te <br /> co —Traqsi�pb�o4er2 P riled yped Name nature Month Day Year <br /> /7 <br /> 18,Discrepancy <br /> 180DIscrepancy Indication Space <br /> n'Residue ❑Partial Rejection I Full Rejection <br /> Manifest Reference Number <br /> lob, <br /> u<- Facility's Phone: <br /> i8o;,Slgn;tureofA]temateFacility(orGenerator) _7711 'Day Year <br /> Z <br /> io.Hazardous Waste Report Management Method Codes(I.e.,codes for hazardous waste treatment,disposal;and TOWN SYStOflla) <br /> 20.designated Faclitly Owner Operator:Certification of receipt of 6zoidous materials covered by ilia manlia4t-except as noted In Item lea <br /> PrinledfTyped Name Month Day Year <br /> 5-7 11141-1, <br /> EPA ForT 8700-22(Key.3.05) Previous edlllons era obsolete. DF-SIGNATEE)FACILITY TO DESTINATION STATE(IF REQUIRIEV <br />