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PIP.q.qp. nrint nr tvinp. [Fnrni rip-cianpri far ime an PlitA 112-nitchl tirnawrhat-I <br />Form ADDroved. OMB No. 2050-0039 <br />EPA Form 87tH} -22 (Rev, 3-05) Previous editions ore obsolete. <br />I <br />DESIGNATED FACILITY'l-0 GENERATOR <br />UNIFORM HAZARDOUS <br />1, Get' orator ID Number, <br />1 <br />2. Page I of <br />1 3. Emergency Response Phone <br />4. Manifest Tracking Number <br />J J K- <br />WASTE MANIFEST <br />5. Generators Name and Maitmq Address <br />Gewator's Site Address (d different than mailing address) <br />Generator's Phone: <br />6 Trzns.Dortef 1 Company Name <br />U.S EPA ID Number <br />T,�msporler 2 Cwnpany Name <br />US EPA 10 Number <br />8 D�.gnats d <br />U S. EPA 10 Number <br />Fa=4,! (s Pnore <br />9a <br />9b U.S DOT Description (,ricluding Proper Shipping NameHazard Clais", ID Number, 113 Containers 11 Total 12 Unit <br />11 Waste CcAes <br />H%1 <br />wo Paiking Group (if anyl) <br />No Type QJ31"Ibrif W1 Not <br />0 <br />F <br />2 <br />1W XkVWV(:1E0 W&M WAS REU rVEj) IIA NDLE A, NO ST( FLED VOR SURS vuqeww <br />05POSAL. TR.1!xTI6L-.%T ()k kn0"t, f A M <br />t5p. C ( TIN- [Mir I <br />F "DX#c S 'USTANCE '.V'-* VJL To <br />.Fo <br />nik F.N,. mi)�4isxf-AL mo rc W11 AGV.44711` q ACk ORD %7M n4l pROV;S 0 <br />Y X01'JVPCk COKUWA110N ANI PFCtiVERY A -T OF 157, -t0CLfjTR W -N AFP)--U*3V-L <br />AND STAU.' RKWIATIUN C905111Y A WERTON W ALL OP a SAII <br />.c <br />rf'COI{DWQ.Y <br />7T <br />14, Spedal Handitrig Instructons. and Additional Information <br />15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, arid are class fed, packaged. <br />marked and labeleid;'placarded, and are in all respects in proper condition for "nsport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter I certify that the contents of this consignment conform to <br />the terms of the sqa,+.ed EPA AcknoWedgment of Consent <br />I imtify INt 91e waste m4imsxabon swtemew, idaalifiecl 40 GFR <br />26227(a).(d I am a large.Quantity, gerreraltor) or (b) (it I art, a small quantity gewalow) is Vue, <br />Generator 'Offerors Prgited/T ed Name <br />SignatureMonth <br />Day Year <br />.j <br />P <br />ili. Intemational Sh!pmeflls <br />F-1 Import to U.S <br />Export fr" U.S. Port ofentry;exit ....... <br />Toin%portcr signature (for exports onlyi. <br />Date leaving U,S,t <br />17, Transpo-ler Ackncmie—Igment or Receipt of Materials <br />Transport 4'PrinrrTyped Nam6! <br />Signature Month <br />Day Year <br />`4 <br />z <br />9C <br />Trott rfed(T- ed Na� IDRy <br />T A <br />'rf <br />18. Disvelparicy <br />18a D'wrepan,,y Indtatvan Space <br />Quantity <br />E -P El Residue El Partial Rejection 11— <br />T, <br />Full R� <br />-,jecljorr <br />Manifest Reference Number: <br />18*, A=tpmate Favl�,,y (of GarleratorD <br />U.S. EPA ID Number <br />LL. <br />Fic,sia.Y, oinonc <br />UJI <br />ll Signafnore of Alremate Faciltly (or Generator) <br />Month <br />Day Year <br />19 Hazardous Waste Report Management Method Codes (!,a,, codes for hazardous waste treatment disposal. and recycling systems) <br />20. Designated Faoli Owner or Operator. Certficalilop of receipt of hazardous materials covered by the manifest except as noted In hem 18a <br />Printed/Typed Name, <br />signature <br />K <br />J <br />EPA Form 87tH} -22 (Rev, 3-05) Previous editions ore obsolete. <br />I <br />DESIGNATED FACILITY'l-0 GENERATOR <br />