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..��..0 Ntrmgnr <br /> f typewriler.l Vorm Approved.OMB No,2054-0439{ 1 <br /> 21 Page 1 4f 3.Emergency Responsa Phone d.Manklesl Tracking Numtxer <br /> 1510-Ui-2128 00386490 FLE <br /> Generator's Site Address(ll d!Merent than mR111n9 address <br /> �fiif�fa <br /> U.S.EPA kt7 Numtar �� <br /> z Company ntar1w y+ JLo U Tri ! e(V Icz tJ_5.EPA1[7 Number r <br /> - Marne and SQta Address c4, C <br /> H9hVVR r tis 32 MkS sotAh of <br /> B14ttyNV99W3 #1V1"3 i <br />:tws PtiUne: <br /> kamar, i1 Total 1I.Sjnki 13,Waste Carlen <br /> 9b_U-S_DOT Oesarpbnn(rndudrng Proper Shipp v Name.H=rd Class,IU 1Q,Container!; i iLj Total <br /> V1t1.fVnl <br /> r and Paciq-Gravp(if array)} N,0. TYi t' <br /> 1. <br /> 3 <br /> 4. <br /> SpecW Handling Instructiorrsand Add+lW%d Inform bon <br /> EM PPE}f Z 3 �,�, �5�' @�R ICY CONTACT JEFF ROWE'S <br /> GEHEIiATOR'S1GFF£RflR'S CER77F1CATlaH: !hereby mare that ltre contents of �consrgnment are fully and 3Geurate[y described above by the proper s5.If x name,and are class+fedi paticaged, <br /> rna�ked and lahere�rpacarded.and are in all reS- I he a proper co that 1 r c transport aecardrng 10 appricahle international and national governmental regdtafians.if export shipment and I am the Primary <br /> E�orter.i rewtfry that the contents of this�sgnrmnt conrorm to Ne leans of the attached EPA Acknowledgment of Consent- <br /> ear. <br />. <br /> Lao 111x1 the waste min 1rti�atiort statement identif e-d in 40 CFR 262.27(a)(if t am a targe quantty.ge9 thna e Or 2rn a small quantity generator}is�tiq., q a <br /> eraZr s Printed+Typed Name <br /> r . <br /> rtternational Shipmen L7Exportfrom U'S. Pari le enci U.S.:t: —� <br /> Impart to U.S. Date avlrin U <br /> isportersi nature far exports ani 1 <br /> ransparterAcVto Worrlent Of Rsceipt of MRteriais anth ay ear <br /> lgnature <br /> M]PrllrtM Pyped Name 1`� 4} I <br /> �i f Mvnlh ❑ayl <br /> Signature ear yam' <br />�ater2PrirrtadlTypedria <br /> scrapancy r� <br /> risaepancy Indicarion Space Type LJ Residue Portia!Rejection Full Rejection <br /> .� <br /> Manifest Reference Number: <br /> U.S-PPA 1D Number <br /> lemass Facility(or Generato(} <br /> h'Y <br /> s Phone: Month Day Year stip <br /> nahire oFAtlemate Fapliry(pr Generator) <br /> moo <br /> ar'dous Wasle Report Management McWrod Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> / 2. 3. 4. <br /> ignated Facility Owner or Operator.Certification of receipt of hazardous material; covered by the manifest except as noted in Item 1$a <br /> Typed Signature _ Month day Year <br /> y. - <br /> i700-22 ev.M51 Previous editions are otisclete. pip, DESIGNATED FACILITY TO GENERATOR <br />