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• Q� • <br /> •`. k5795r# 57862 <br /> PIr o type.{ designed for use on elite 12-lloh writer, Form proved.OMB No.2060-0039 <br /> -i UNIFORM HAZARDOUS 1.Generator 0Number 2.Pap 1 of 3.Er wpncy Response Phone 4.Man re ng kumber <br /> WASTE MANIFEST _ 0 0 5 61.6 0 2 4 • JJ K <br /> 5,Genere&s Name and Ma1lft9Addrm Generetote Site Addrw(0dfwent than malling eddress) <br /> #026,Depot CM M'Attu..Hole Depot c5l HOIS DKIOT 01116 <br /> 5151`silll-reiipe HOW OSPOT'M1116' 23r'{33uflC13'_AW <br /> genwilowba.fl 77156 (8661303-7141 WTECA CA 95336 (2191825-9139 <br /> 6 Transporter 1 Company Name . 7 U.S.EP D =er ,1 <br /> 21st CENTURY ENV=*ZiML HMGEMM �' 4 -L LLG' CARO 16401.2— <br /> 7 nen 2 Compan Name: U S,EPA D Nu r <br /> �Q <br /> B Designated Fa and M Address U.S.EPA ID Number <br /> BMINGTE,UnRo#BfSI m, LLC. 1W FACILITT <br /> 21245.?746.AYSBOS:80tiTfl <br /> 'Fa '.sPhortat ' NA 98132 {-253p 872-113 ` WAD991281:76, <br /> ga Rr.U S.DAT Description(Including Proper Stripping Name,Hazard Close,ID Number, 10.Contelners 11.Total 12.Unit 13,Waste Codea <br /> HM 'and Paddng Group 9aoY)) No.. TM, 4uan0ty wwa. <br /> rte'.' <br /> :2 (0141=115 PF oil 1035 331 <br /> eggr x , <br /> E •i <br /> rkwidlin, H0993 - 119(128) FL B L008BPACI {' - .OR'S/DFFEROR+S'CEIMFICATION:I hereby declare that 5r®cordelds of this consignment are fully and aocurstelydescdbed above by Ste proper shipping name,and am dmsfled,packaged, <br /> maendiabe and aiatn.all respects In proper oorWl Wn for transport according to applicable Intamational and national governmental regulations.It export shipment and I am the Primary <br /> g l mer laert>fy-Otatth4:c�ntq*-otpd§.consEgnmerdcadormtothe emnsofthedlached•EPAAdmowt*mrmIofCosent <br /> + , 1 certry 9ret.ttie waste' n sfatementidenitfiad.in 40 CFR 262,27(s)(ti I am a large quamhy generabr) am a and Wentily generator)Is ince. <br /> Genatatods101fero�aPdnte Narver S Month <br /> tt�honatShnpmerds >�Imp<xt to U:S. ❑Export ftom U.S. Pat Of amrytexH: <br /> s `'� - -- ---•.....-- - --- — ---- ---- --- Daleleavhg U.S.: . _. . _ -�ra` '+-.:.- - - <br /> :-•rTfansporters�ture.((aexpwtsarNk: �-...-- <br /> ;17:Transporter ptortFoi.Recelptni Matednie 3 <br /> Tie i'Pdn. Name.,:, Sigtslure hlorrtiv Day Year. <br /> Nlontitr ;Day Year <br /> 'TransM yped Name ; Signature s. <br /> x :18;Discrepancy <br /> ;18ec Indkfon Spew, —t ❑Resld� Q Full Rejection <br /> . s <br /> CluenmY ElType Qar)fe)ttej5on <br /> hbrdtest Reference Number. <br /> 8b.AtienmtwFacil ty(or Genwabr)' UcS.EPA IO Number <br /> 1 <br /> a; <br /> rs. ,FadOlys,Phone: <br /> Signature of Alternate FeAtIr(or Generator) Month Day 70ar <br /> U);`19,Hazardous Waste ReportManagament Mathod Gods(I a,codes for hazerdouswaste 1rea6nenR dwposal,and reoycing systems) <br /> LLL <br /> VIAL <br /> 14, <br /> '2670koifedFad10yOwnerOroperetor CeilEftdbt'61*Weiptofhizaidous'riialwWschverodbyQve-m&h estexosptes noted InItem 18a <br /> EPAoM Dy <br /> •N u . <br /> { TATE"{IF"RE'QUIReEarD <br /> )Form8RPrevlousQNons•areobsolete, DESIGNATED <br />