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Please print or type.,( designedfor use on elite(12-pitch) Peiter, ty <br /> UNIFt3RM U$ 1 rlDForm Number Fo <br /> WASTE FEST Yed. <br /> 6.Generators N ( Resporea P 4.MardfestYraokin Namber <br /> 7_0 Generators Sit®Address(�f dNFt than matte' <br /> l.` ng address} <br /> Generalors <br /> 6.Transporter i Company <br /> EPA <br /> 7.Trensparter2 Company Name i i. i.:-•+ ID'Tow 4-1c ) <br /> U.S.EPA M Number <br /> 8.Designated FacStyName and SdeAddres C� <br /> _ FadNtysPtwne;�.� �E::''� y C.l.i -��.�� .�•.�`.:�,•^•�..... 4 �: <br /> ga 9b.U.S.DOTDescrip f <br /> mduding1erPPbl4 Marna,Hazard Clens It)Number <br /> MA(• andPaddspQouFCdany}} 10 <br /> `.. i.:Total _ 12.Unit <br /> 1. 1 4 <br /> -�,�•y t Na 13.Waste Codes <br /> � l�''1 1 #,,, s, 1YPe Qu. ttty.' WtNof. <br /> c� <br /> LU <br /> 3. <br /> FEB <br /> 216 <br /> 4. <br /> td '... PAR #I kr buconaAitinidomaon14.s ta <br /> 15. GENERAl1DR'SIOFFEROR'S C '�" �Cr <br /> marked ante tetiet ERTIFICAYlOM:t hereby declare that the contents of this pond.=ant are !/ <br /> �Yt�S�f <br /> edrt tit,, ed-and are n ate resPects in proper condition fortranspwt accale to a atxuiatety described above by gre proper shi <br /> Exporter,l cedrTy that the conte of this cons g PPf�le intemagor�arid nag=[ PPln9 name.and:are dans <br /> I ttati�e waste ' lament +►to the terms of the abdhed EPA ent of ConseoL govaamenhai regulations.liexpod shiWneat•aad I am Primary d <br /> n statement. in 40 CFR 26227(a)(if l am a large quantity <br /> GeneaawdoQerars.Priatr yP�lVanre 9 biY gani.e�`r3}�tpopr}a(6)fd1 am a snreN gr'amNY generator)Is titre. <br /> I` I+ j 4I <br /> Year <br /> Import to U.S <br /> Transporter signature(tor exports orM. U Export from U.S. Port of entryfe* <br /> A 17.TiansperterAdmowledgnrerrtof <br /> ' of Date leaving U.S.: <br /> OAC TranspoRer <br /> Signature <br /> Transit 2 Printed/1 E` d ` f-`" Y <br /> ti Yt Nine St nature' <br /> 18.Discrepancy i Month Qay Ye <br /> 188.Discrepancyhtdktation Space Y <br /> . .. D Quantity <br /> ❑Residue ❑Partial Re}action ❑Full Reaction <br /> 18b.AgepiEte FadNty(a Generator) Manifest Retaence Number <br /> U.S.EPA t)Number r <br /> Facill Phone: r <br /> { 18c.Stgnature of ate F <br /> (orGeneretor) it <br /> Month Day Year i <br /> r 19.Hazardous Waste post Management Method Codes i (� <br /> 1 f,! r (e,codas,for frazadous waste UaatmenG di�osat,acrd raaydM9 syst8ma} �P <br /> 2 3. <br /> 4. <br /> 20.Designated Fadfity Owner or Operator.Certification of receipt of haUrrious materials covered by the manifest ex <br /> Prte yped Name �as noted in Item 171 <br /> 8a <br /> afore <br /> 1 Form 87 Mortlh t)a <br /> 60 22(Rev.., 0� Previous editions are obsolete. r Y year, <br /> .'• .i -._._..rte^_- �r`f <br /> . _ TRANSPORTER'S COPY <br />