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Form Approved, Citi No, 2050.0039 <br />Please pi: at or type. (Farm designed for use on elite (12,p1typewriter.) <br />a,M 1 of 3. Emergency Response Phone �. RAantfe88 TtaC 9tNudsr <br />1. Generator 10 Plumber � � � � a � J <br />UNIFORM HAZARDOUS � <, t � � w-4, <br />WASTEARBFEST Generator's 5st®Address (if different than maiting addressd <br />. Genera 'S Name and IReiir Address <br />Ocnaraar`s Phene" U.S. EPA ID Number <br />6. Transporter t Company Name <br />' ` U S EPA tO N3mber . <br />fBnSO >ny I a 1er °r <br />§... B <br />EPA 10 Number <br />T <br />8 <br />U.S, <br />S. es r ftp Na sad .,. ass <br />Fa i tvs Phone- r 4 <br />3fl- Containers 11, Tohai 12. Und: 93, ;rxiaste Lades <br />ua 9b U.S DOTC1esp un (=nU rd Prer Sh;pa€ng fi ame. F#azaetl C ass. ID Number, No, Type duan# ty Vvi tVo1, , <br />HM and Packing Ci?rniry r:# anyi) <br />w; <br />r <br />v <br />Uj <br />AOR RECYGLi�' ► s x <br />o <br />tis a.ht :.st c„. <br />t <br />14 Speu ar xar 11 ng Instructions and Addriorial information <br />g� <br />the <br />P JET <br />e proper <br />ing name, and are <br />15 GENERATOR'SIOFFEROR'S CERTIFICATION: i dedale that <br />cfocontents ansp ri a cord€n gore n4 arbte nt matonal a, d ®e MIY and 3=, ratety, tuna anscribed ve nmenishres a ons."if pPeapo t hip e ansl # asr e Pninaryd <br />k ann l� e:e aearded, a rd a a in a.I rpec s m p aPe' gI <br />E - , , cedify that the contents c f this cons , nlem cstnform to the term of the ached EPA Acknowledgment of Consent <br />i ceftity that ri e waste Miffs n;zati statement idemfied in 40 CFR 262,27(a) (i# I an a larger quantity generator) or (bj (if l am a stmt quantity, generator) is tare MonfhDai' Year <br />sonature <br />bene a of n r s Pn t r gr <br />" .. <br />96 <br />lrltematmral Shipmen1w <br />6 x Pori of ene�.—.� <br />Imo€t to US: E froi .S _ <br />Date Ieaiiing U.S.: <br />Tran3pnstAt.�natun{fo=€xpor$svn;y: <br />W 17, a! Receipt of Metinia!s P tenth Dap Year <br />wSignature <br />fro spwo'en1 li tfid Typed3n a s Ltop Year <br />y, I <br />rrans�ftoipriF$Adamc f t 5getlue( <br />18 Dkve,' ncv L�--y <br />El Type Residue Partial Rejection L 1 Full RejectionRejection18a. [7sscreparcy Indicate') space 0 QTvuantify p <br />Mari Reference Number, <br />U.S. EPA ID Number <br />Ilia. Ahemate Facility (or Generator) <br />tie Fa,,;RysPhzinie Month Day Year <br />OI8c. Signature or Xternate Facrliy (or Generator] <br />15. stator uus ;ase Repo t R4a age nor t Stethod Codes (I:e., cedes #rar hazardous waste treatme rt disposal. and retyycng syste=ms} <br />a <br />s a. <br />. <br />the manifesUj <br />t except as ratted in herr+ 16a <br />20D.�nated F, or operator- Ceft+Bca t�reae i rata mated cova� { p <br />h d ( s 5, Year <br />,#n'i2 (.ry yr3j #V't1� <br />PY <br />4, <br />- <br />EPA Form 87OD-22 (Rev, etlitii are <br />