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Please print or pe,(Form designed for use.on elite(12-pitch)typewriter. <br /> 1.Generator ID Number 2. Form Approved.OMB.-No. <br /> 20 <br /> UNIFORM HAZARDOUS Page 1 of 3:Eineguincy.Respornse Ptone 1124733014 <br /> ifest Tracking umber.. <br /> WASTE:MANIFEST � 1 344.5'714- JJ. <br /> 5.uene�reltM N�aam�ep a/nd Marg Address Generstor's its Addresjs Of�derent than mating address) <br /> �Y•,iR..6«KBORP SRrq./•. - S•I�RL-.nM•I�^V".r•.It./.wl�P,A•. <br /> . sg�LJV/l3 ViY1 CTR -- ... <br /> Geulerakr's.Ptrone: •5T4� i52• <br /> 6.Transporter 1 Company'Name U.S:EPAID Nuirduer. <br /> 7:Transporter 2 Company Name U.S.EPA ID Number <br /> 8. ateV :Pimm and Stle Address U.S.EPA ID Number <br /> ✓ 7F MFISIV INC.'. <br /> E)Jt, tllL2Lf'? d5°+ <br /> ` 18A�Ct~ftE , 4 53807 <br /> Sus 96 U:$bbTgesaip (aidratn9Propar ShipPin9Naive liaxard Glass,ID NumWe, .:: 10..Contakters 11.Tial 12 Unit . <br /> (gyt arid,Pecic{�Grdrup(tatuy)) <br /> Na. Type QuantityWWoi. i3.Male Codes <br /> htr a :,400 le r � r t;II ftp alta ttiel 3 <br /> 2. <br /> CR <br /> f IE <br /> 3. x �' <br /> FEB I <br /> 4. <br /> HES <br /> 14.Special Handling Instructions andAdd'itional IMoumation <br /> eRG 0171 - tl'1n7t�ltsE '1, ,....4? �S"•a C: 1 <br /> In L1 <br /> A--T2 <br /> 15. 13ENERATOR'StOFFEROR'S CERTIFICATION: I bereby.dedare that the contents of ids consignment are fully knd accurately described above by the proper stopping name,and are classified.packaged, <br /> marked and labetedfpiacerded,and are in all respects In proper condition for transport according to applicable international and national governments]regulations.If mW stopmerd and I am the Primary• <br /> Exporter,I cerfdy that One conents of Ods consignment conform to the terms of the attached EPAAdorowdedgment of Consent, <br /> I certify ghat the waste nn naatian statement Identified in 40 CFR 282.27(x)Of t am a large quantity generator) .,(b)Of arp a smallquantity.generalor)Is true. <br /> Generators/Otferoes RinteNTyp4F Name: _• {ee f [ S�rha ; M(n�ra Day Year <br /> 16.International ShhpmQ.n •.w 1! .. ,t - r. \ it <br /> i= W LJ Import to U.S. ®f3dpoR from U.S. Port of errirytexft <br /> Vansporter signature(for exports only): Date leaving U.S- <br /> 17.Transixate'Ad=WedgwdwA or RK W pt of Matedals <br /> TM'ut;LT 'gni MOnth Day <br /> dAiegze.ejalm Ic [MI <br /> a _ <br /> Tmerspadw2PrintedffypedName Signature Month Day Y• <br /> 18.Discrepancy <br /> Of <br /> 18x.Discrepancy Indication Space ❑ Ouamtty ❑Type 0 Restore ❑Partld Rejection Fug Rejection <br /> Manifest Reference llunber: <br /> t8b.Alternate Faa'81y.(orGenerator) U.S.EPA ID Number <br /> J <br /> ra <br /> ri Facgiti(s Phone: <br /> loc.SigehatoeofAlternate Facility(or Genera" Monti% Day Year <br /> 19.Hazardous Waste Repot Management Method Codes(Ge.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> t• (L 2. 3. 4. <br /> 20.Designated Fi dzlily Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in te"m tea <br /> dntedffypede <br /> Moth NamS y <br /> r t ; tgnature: . pay •l ev <br /> EPA Farm 8700-22(Rev.3-05) Previous editions are obsolete. TA^NSPORTEER'S COPY <br />