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Please print or type.(Form designed for usn on elite(12•ti tch)typewriter.) Form Loned.OMB No,2050.9039 <br /> UNIFORM HAZARDOUS 1.,G,�e+neratopr�ID Number Z Pago 1 of 3.Emergency Response Phone 4.Manifest rraacking Number °y �p <br /> WASTE MANIFEST G: �t 0 Q 0543 17 rz t jq" Sj & U 1 Q .4 0 1 °� JJK <br /> 5.Gsnsrator's No MalNng Addras Generator a SbAddress(if d lfarect than mai#tg address <br /> ,92-0,0 5 OL D,01ZA D 2 <br /> Gonomlot's Phone: <br /> 8.Transpodar 1 Co nper>y Name _ U.S.EPA 10 Number <br /> 7.Tra tsl)uler 2 GtunpanY Name (} fjr?EPA I Number <br /> 8.Das&W Pa Name and Site Address U.S.EPA ID Number <br /> 163V W !4V- !;T <br /> Facility's Phone: <br /> ga, Wa.U.S.DOT Duc p VrAv ng Proper Stdppin Name,Hazard Case,ID Number, 19,CaMamera 11.7bW 12.Unit 13.Waste Codes <br /> HM "Pac02C-rap(dany)) No. Type Quantity Wtivoi, <br /> X'-F& AIAZ <br /> o 9 ldlu"k t�il� r utAf �/ <br /> d <br /> aaFt'.r4 <br /> Lu 2 <br /> q• <br /> 14. pedal Handling Instrucdons andAdditfond information <br /> f p. <br /> ( t <br /> 15. GENERATOR'SIOFFEROR'8 CERTiFiCATiON:i hereby dootare fiat the contents of this consVvTM are My wW act nWy dowihad above by the proper aNppN mono;and aro dassigad,packaged; <br /> mae od end labeloWMacarded,and are in 4 respects in proper cordtfon for transport accordxtg to appilcabtd International end national govanntental regtMons.If export stUprrtent and Ism the Pr4hary <br /> Exporter,I certify teal the contents of Ugs conslgmmrit conform to the+amts of the attached EPA Ad nawf idgntant of Consent. <br /> I certify that the waste min rNmOon statement Wentfiad In 40 CFR 262.27(a)(If i ant a large quantity Donerator)or(b)Of t am a mW quantity generator)Is We. <br /> Ganaratoa s/ONamt ss Printodityped Name tiro Mot tit Yoar <br /> y r r <br /> _s 16.International Wp fonts t <br /> t_.1 Impat to Us, ❑Expert from U.S. Portof enwakt: <br /> Transporter stgnaturo(Rx exports oidy): Dano leaving U.S,: <br /> w17,Tranaporte Ad wtdodgment of Roc4t of Materials <br /> r TransporterLPM'W_ypW`N_3jQAn <br /> yped oma SSgftaturo Month Day Y. <br /> Oa dt &JIA <br /> z Tran 2 Signature Month Day Year <br /> 18.Discrepancy rr--� <br /> 18a,DiscropancyUd�tlon Space ❑ Cl ntily LJTt+pe ❑R.W o ❑Partial R*don ❑FW R*don <br /> Manifest Rolomrice{umbar; <br /> iBb,Nemato#Facwry:[ Gotsator) U.S,EPA IDNusfer <br /> is <br /> >'scfNiy's Phano: <br /> 18c.S gnalu o of Akemato FadiifY(or afalo) k�nth Day Yaar <br /> 19,Hazardous Waste Report Manageownt Medwd C66 (0.,codas for hazardous waste Imaimol,disposal,and racyckrV syslorns) <br /> 1, 2. 3. 4. <br /> 29,Doskyaated ftKry CRaner or Oparotos:Certification of receipt of hoxatdous matortafa oomed by iho manifest w oopt as nded in Item 18a <br /> Pr n <br /> .:-- Marnttt Day Year <br /> EPA Form 87011-22 v.3.05) Previous editions are obsolete, DESIGNATIKFACILfTY TO DESTINATION STATE QIFREQUIRED) <br /> l <br />