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Pleaseul tr typ (Form designed for lyse on elits(12 pitch)typlewdler.).;I"'. t 'n` '1 Form Approved.OMt3 No.2050 0039
<br /> 1.Generotdr ID Number' t = 12,Pa a 1-of' 3,Eme en Res onse Phone 4.Man€fest'Trackin Number
<br /> UNIFORM HAZARDOt1S „ ;�, ..r:: '[;::j: .Fig 9 of p �y f1
<br /> WASTE MANIFEST < G3,.;1't.r' .:' Et>�;,
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<br /> 6.Generators Name and Mahing Address _ f y• / Generator's She Address(if digereal Than mailing address) n
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<br /> Generator's Phone:
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<br /> 6.Transporter 1 Company Name U.S.EPA ID Number (_
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<br /> 7,Transporter 2 Company Name U.S.EPA ID Number ' F
<br /> 8•Designated Facility Noma and Site Address U•S,EPAID Numbei""
<br /> Lx:magvio/Kl ("I;rf oN
<br /> 2000 N.MAMMA ST1 B-A
<br /> 60PAPT c)M Gr. OG122?
<br /> Facifitt+aPhone: 311,011€1f-'r'1,00
<br /> ga, 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Contalners 11.Total 12.Unit 13.Waste Codes
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<br /> and PackingGroup(It any)) No. Type Quantity WI.Nal,
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<br /> 14.Special Handling Inslruallons and Add€pori I Inlordis€lon
<br /> -30 2-9000 WOOS Tf:Rllrilt`tAL"- NAERG##315:1_:111-'' PROFILE 4,9131:(ALY`WATER. ;.,_w.
<br /> A1P R i r`.iAfE PERSE01`4AL f'11OI EMIVE 7EQLIIPMh-N w"I'A0TS'INJVSSH FQ 011 1 1f ATF.R. r
<br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION; I herebydedare that the contents of this consignment are fuhyand accurately described above by-the propbr shipping name,and are dossif€ed,packaged, i.
<br /> ritarked and labeled/placarded.and are In all respects fn proper condition for transport according to applicable International and national govammental regulMlons.It export shipment and I am the Primary
<br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgmanl of Consent
<br /> I certify the the Waste minimization statement Identified in 40 CFR 262.27(a)#[I am a large quanftly geneiator)or(b)(Ill am a;small quohfily generator)is trjio,
<br /> �e emtoes1OF{erdr'sPrfnledliypod Namaf 5�lgn ltTre Monllr Day` Year
<br /> ...r 16.International Shipments
<br /> D Import to U.S. ❑Export from U.S. Port of entrylexll:.
<br /> Transporter signature(for exports only): Date leaving U.S.;
<br /> 17.TranspoderAcknoviledgmant of Recelpt of Materials..%
<br /> TransportgtI dnledffyped ame:t / J Signature } Monlf,4 Day Ya M'
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<br /> Transporter 2PrinledffypedNam� Signature Month Day Year
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<br /> 18.Discrepancy
<br /> 18a,Discrepancy Indlcallon Space quantity ❑Type ❑Residue ❑Parlial Rejection ❑Full Releedon
<br /> Manifest Reference Number:
<br /> 18b.At(ernafe Faclfity(or Generator) U.S,EPA ID Number
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<br /> Facllllys Phone:
<br /> 18c.Signature ofAltornaleFachily{orGonerator) 4 Month Day Year
<br /> 18,Hazardous Waste Report Management Method Codes(I.e.,codes for hazardous waste treatment,disposal,and racytsling systems)
<br /> 20.Designated Fadlity(Avner or Operafar;Cerlllloation of recefptof hazardous mateflals covered by the manifest excapl as noted In Item 188
<br /> Prinle pe ame g 5 gnalure �) + onth Day oar
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<br /> EPA Form 8700.22(Rev,3.05) Prevtoua editions are obsolete, 1015-SIGNATED FACILITYTO GENERATOR
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