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Pte tint ortype.(Form designed for use on elite(12-pitch)typevvdter) ForrAApproved,OMB No,2050-0039
<br /> UNIFORM HAZARDOUS 1,Generator ID Number 2,Pogo f of 3.Emergency Response phone d.MaannnifestTracking Number
<br /> WASTE MANIFEST 'J 00209,'�'4` 1 900--424 Q; V 17 5 8 4 U 9 5 JJ
<br /> 5, en fors ami elle dress Generators ite Address(If different than mallag address),
<br /> 3927 •� a�� �'Ds�igLparyAp,M Att�ir �ieea:gtan
<br /> S• ftaak +fir' �W-9 2vtii ' ,a.�•�r,r��C,• , ��.1'try „!„ L",���t s.r�� ' ITale4h7
<br /> gemaraior'sF'lione:,��.� '•;dib-�395SiNy'' ,
<br /> B.Transporter}Company Name U.S,EPA ID Number
<br /> 7.Transporter 2 Company Name U.S.EPA ID umb%
<br /> asi uteri F cii am'and Site ddress U,S,EPA 10 Number
<br /> 2pOt1»7fW�tfkt.�•.;St'�1bHr� •+.
<br /> Facili sPhone:',�a�rlf- 7',—� 1i0
<br /> +, 1
<br /> ga Ob.U.S.00TOoscriplion(Including Proper Shipping Rome,Hazard Clais,ID Number, 10.Conlainers 11,Total 1t UnIt }3.Waslo Codes
<br /> HM ,end Packing
<br /> } Grroupdan.y) { •• , ''. s• \No, Type Quantity WNol.
<br /> Ix wmte
<br /> 'Lit
<br /> �y
<br /> IY^�+ { ' 'Oil'+ ,1 •} "1r ' +r G
<br /> 2. 1 777 ll
<br /> w
<br /> ca
<br /> 3.
<br /> 4,
<br /> 1 pe dM mst aU s and Additional lnfngna8on
<br /> 3ti a >2�5; �t L`D3Y t Cii tt "AaB(600)42'$--9300 AIAt�. ?.ftp ��ir•
<br /> 15. G$NSRAT(rR'sfDFyEROaS CCRVICATfoN;i hereby declare that the contents of this oansignmenI are My and accurately desorlbed above by the prcpershtpping name,and are classlped,packaged,
<br /> marked and;Iabaladtpiacarded;liber are in aM respells in propor candiliom for transport acoerding to appMcabfe fntematlonaland national governmental regulations,If exportshipment and I am ft Primary
<br /> t I porter,!reiuty ffrdt thgrdntenis oflMs wnsignment conform to tho tones of U a attached tipAAcknowladgment of Consent.
<br /> 1 garhfy thatAiewasteiitinlmiial3ori statement identif�d to 40 CFR262.27(a)(if 1 am a large quan8tygenerator)or(b)(Iff am asmali quantitygenerator)Is true,
<br /> lota(Oiferota nuledffyped ame Signature Momh Day Year
<br /> 16.In Shipmemis t t
<br /> u Impod to U.s, ❑Export from uS, Port of enirylozib
<br /> �.Transporior sfgnaturo(fore orta only): Date leaving U.S.:
<br /> � •}7,TransporterAcknovfiedgmantofReceiptofMatedois
<br /> Transparteri Printed/lyPM Name S a Month Day Year
<br /> 7ranspotler 2 Pdnte lTypad ame store Month Day Year
<br /> Dfscrepamcy 4
<br /> 18a.DlBcrepsncy Indication Space ❑Quantity []Type ❑Residue nPortal Rejection
<br /> i t J Full RejecUon
<br /> Manifest Reference Number:
<br /> 18b,Attemate l acillty(of Ganorator) U.S.EPAID Number
<br /> w FaGtlty'sPhone:
<br /> .l eo•Sgnaturo ofAlfamate,Fa'ily(or Generator)
<br /> Month Day Year
<br /> }O.mprdousWasteReportManagementMethodCodes(Le„codesforhazardouswasteUeatmenl,disposal,andrec ftgsystems)
<br /> :1. 2. 3. 4,
<br /> 20,Dosignatetl FacNlty Ownsr or Operator,C;AMicaiion of receipt of hazardous materials covered by the manifest except as noted in Item 18a
<br /> Pante . peName
<br /> Sgnatum Month Day, ear
<br /> EPA orm 6700-22(Rev,3.05) Previous editions are obsolete. q I t
<br /> DESIGPIATED FACILiTYTO IIESTINIATIONf STATE(IF REQUIRED)
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