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Please print or type.(Form designed for use on elite(12•pftch)typewriter.) Form Approved.OMB No,2050.0039 <br /> UNIFORM HAZARDOUS 9.Genorator ID Number 2.Page t of 3.Emergency Responsa Picone 4.Matilfivl-lrecWng Number01173As <br /> WASTE MANIFEST (.". 6_t',t 13 a3`F T, 416,923-87 2 �� P e <br /> 7 FILE <br /> 5.Genetato+`s Nemo and tdai'i-q dross Gar araWes Site Address(U dmorent man ma Eng address) <br /> 32(10} E t~)"�ffto 5;. <br /> �1ri�kt?rr<r�'M. �a <br /> Gcnerata s Pncn&: :"r33-Q>1 <br /> 6. ransportort panyNam& U.5.EPAiDNr <br /> 7.Trans{o tar 2 Company Name US.EPA ID Ntmtbe" <br /> 8 Designator Fackiy Name and iteAddress U,S.EPA ID Number <br /> Fora!/s PnonS t ?-.4 rpt .fit�Aa"xT oCl j d P20 U,""fit <br /> oa, 9b.U.S.DOT Deseriptarm(nChOng Pmpor Sfifw'rg Name,Hazard Class,ID Number, 10.Contalners 11.Tota( 12,Unit 13,Waste Codes <br /> HM and Padirg Gratia(it any)) No. Type Quanwy N'UYo4. <br />{ t. <br /> Rx .: i fir`±rater,, _, 1s` i'� asit; ;H a"p ";? Ufa j•x 3 ,€ <br /> i <br /> LU <br /> z 2. <br /> 3. <br /> A. <br /> t4:Specal Hard�?tg insWC.iarss andAddd�tmat Infomsa6ar .�. <br /> (t-;YC!;R%PRO !"f pt�.')l'Ci"R <br /> a ofi?js 4041 1G 01-WS <br /> 45. GENERATOR'SfOFFEROR'SCERTIFICATION:Ihenthydedarethatthacontents;ofMswritigrxaentamfull and arckca+xtydesatedRbontrythe r no.erdareda"AW, , <br /> markc-d anti taboiedi(Aawrded,and are in 0 respects in proper conom for transport atcadat9 to ap*aNa international and national gwommantat rogutatims.If exW shipment and I am the kir" <br /> Extorter,i certdty that the contor:is of this consignment conform to the terms of Use arladW EPA AcknowiedrgmerA of Consent <br /> I wrfrry brat Use wasta K-rimization s+atement&akd in 40 CFR 262 21(a)(d i am a large quantity generaVd)or(b)(d I am a small quantity generator)is We. <br /> r,&ratoa'st .o s ro t'� � cJ a � , ay ear <br /> 96.Er:&matona€Stipm°nts Import to U.S. ❑Export from U,S. Portof er tr iex'st <br /> Tram"ler 'nmwe(tor ex s Data leav U.S.: <br /> a 17,TransperterAritj)oi�d Rpaipt of Matcr� <br /> Tea r i PnniodR}ped Nacos oro Zy Q <br /> f1w'r Lr <br /> my Transpoder 2 Prn<redayped Nam& tura Jt ear <br /> 18[i'wepar'-y (r--�I rr-� <br /> 183 D-'CmpaMy k&vten Spaca Lurantzy a_JType ❑Residue lJ Partial Rejetbon ❑Fu`1 Rom. <br /> Manifest Relarenco Number: <br /> IBb.F.ernato Fad'ay for Generator) U S,EPA ID Number <br /> w Fadtt's Phone: <br /> w 18e.S$natsraolAN.ematafaaaly(rrGar!anatCt) lAonUt Day Year <br /> z <br /> t0.Hazardous tYaste Rapa9 ManEgtmm&nt fAaiAod Cases(i.e,.,codas for hazardous xvasta troaWcnt,disposal,and recyd`rsg syskms) <br /> ® t. 2 3: d. <br /> { 20.Dasgnaled Far 3y Oh r or Op&iter Csrulmbon cf rece:p t of hazardous matena's covered by the manifest exoetR as noted in ham 183 <br /> Print dllypad <br /> Name bignatum % Ur y <br /> EPA Farm 8700.22(Rev.3.05) Previous editions are obs®}efe. DESIGNATED FA TY TO GENERATOR STATE(IF REQUIRED) <br />