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Please print or type. (Form des' ned for use on elite (f 2 -pitch) wri#er.) Form Approved. OMB No. 2050-0039 <br />UNtF(}RR'HAZARDOUS t • Generator IDN 2, Page 1 of 3. E envy Response Pune 4. t T ng Number <br />" �r> <br />STE iF16ST , . � � U <br />5, Generator's Name and Mailing Address Generstors Site Address (it different than mailing address) <br />Generators Prow <br />6. Transporter t Company Name U.S. EPA ID Number <br />7, Transporter 2 Company Name U.S. EPA ID Number <br />8. Des,grsated,Facility Name and Site Address U.S EPA ID Number <br />Facility's Phone. <br />ga. 9b. U.S DOT Description (incWtV Proms Shipp" Nom, Hazard Class, ID Number, tQ. Contai11. Total 12, Unit <br />HM and Packer Group (9 anY`,) No. Tye Q-ntlty VdJVol. 13. Waste Codes <br />i <br />uj <br />f <br />eu <br />2 <br />� _ l <br />k <br />4. <br />l <br />1 <br />14. Special Handing Instructions and Additkinal Inlomation <br />;r <br />. ,. s.,,. <br />15, GENERATOR'SlOFFEROR'S GERTtHCATtON: I hereby declare that the contents of this consignment are fully and accurately described above by the prow shipping name, a rd are classed, packaged. <br />marked and tabeled,'placarded. and are in as respects in proper condition for transportaccoming to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, l certify that the contents of this consignment conform to the teras of the attached EPAAcknowledgment of Consent <br />I certify that the waste minimization statement iderifified in 40 GFR 262.27(x) (91 am a large quantity generator) or (b) (4 f aha a small quantity generator) is <br />Generatots'Offer"aptintedfi Name Sr tu+e Month Day Year <br />..t 16 International Snpoents f� (�l <br />F-- U Import to U.S. L f Export from U.S. Port of e. tryfexit: <br />E Transporter signature (for exports only): Dais leaving U.S.: <br />17. Transporterftn niiiedjment of Receipt of Materials <br />W, <br />iransp i tar i Pr s taiypad Name r Signature Month Day Year <br />Q Transporter2Prkrted(Typed Signature Day Year <br />18, Discrepancy <br />18a. Discrepancy Indication Space El <br />tntity n Type ❑ Residue El Partial Rejection El Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: <br />t 8c, Signature of Alternate Facilky, (or Generator) Monro Day Year <br />19. Hazardous Waste Report Management Method Codes (ie.,codes for hazardous waste treatment, disposal, and recycling systems) <br />UJI 1,' <br />20. Designated Facility Owner or Operator: CQrtlficaW. of receipt of hazardous materials covered by the manifest exceplastoted in )tem Ise <br />Printed{T Nam S' tura' Els y <br />EPA Fon 87OD-22 (Rev. 3-05) Previous edifiare obsolete. DESIGNATED FACILITY TO RAT <br />