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se print or type.(Form designed for use on elite(12-pitch)typewriter.) Forth Approved.OMl3 No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.EmergeneyResponse Phone _TF-Manifest Number <br /> '954 FL <br /> WASTE MANIFEST l iit;p,�<; <br /> 5.Goneratoes Name and Malting Addressnerator's Site Address(ii d fferent than mailing address) <br /> !rI"ST`S',moi ixi7i',izt;4""'��stiFlc.°r �1ft nttlilzt+Y;f�lNrtrlsrh>t <br /> N.NDes Phone:1111" <br /> porter 1 Company Namje U.S.EPA ID Number <br /> $)r3rf4'rOf-s 0"), <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated FaRity Name and Site Address p- 1 U,S.EPA 10 Number <br /> d., L3 iii*llr�crnierit�( 4Yr"x"4 NY tar'+�!i3 <br /> Facilit Is PhCi+ xr""i-4w'r t4 t r r Yt3i?t4.V fi s# it.SY 1Fc <br /> 9a. 9b.U.S.OOT Description(including Proper Shipping Name,Haserd Class,ID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes <br /> HM and Pecking Gmrip(dany)) No. Type Quantity WuVoi. <br /> -0 4T l a�r." r„':.i'roi.ta+'hx ..`:: r�-"<°t. :„L:6it. f}"i>.tt Ft_ 4.�,atEtdf�ri; -"" fl'.� °r' .• � . <br /> ui <br /> 3. <br /> 14,Special Handling Instructions and Additional Information <br /> 15. GENERATOR'WOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and acciately described abm by the proper shipping name,and are classifail,packaged, <br /> marked and iabeledtpiscarded,and are In all respects In proper condtion for transport according to applicable international and national governmental regulations.if,export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the tars of the attached EPAAdmavledgment of Consent. <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(x)(it I am a large quantity generator)or(b)(d I am a small quandsq ganeretor)Is true, <br /> Hera oe s n yped ams re ' n ay ear <br /> X.International Shipments <br /> �. '❑!moon to U.S. ❑Export From U.S. Port of entrytexit: <br /> �: Tran ors"naWre for ax its oni Date lea U.S,: <br /> ' <br /> it 17.TransporterAcknowledgmant of Receipt of Materials <br /> Uj <br /> I.- ran vier 1 FNitedAyped Name <br /> . (( y y ear <br /> [@Z Transporter 1-P—drteWyped NomaIhnth Day Year <br /> 18a.D€scxepancy Indication Space Quantity LJTypo Residue ❑Partial Rejed n t 1 Fup Reisdlon <br /> Manifest Reference Num: <br /> 18b,AJWada Facility(or Generator) U.S.EPA IDNurinber <br /> c� <br /> Fad!itVs Phone: <br /> 18c.'SignatureofAltemateFacility WGenerator) Month Day Year <br /> d <br /> � 19.Hazardous Wasle Report Management Method Codes(i,e.,mdestar hazardous waste treatment;disposal,and recy&.ig systems) <br /> 20.Des}nsted Facility Owner'&Operator.Cartkation of receipt of haiardous materials covered by the manifest excep4as no kt ltetn:18a <br /> PnnWfTyped Name Sigristura Month :Day Yea` <br /> EPA Form 870022(Rev.3-05) Previous editions are obsolete. TRANSPORTER'S COPY <br />