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• <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />0 <br />Form Aaaroved. OMB No. 2050-0039 <br />EPA Form s7W-V (Rev. 3-05N"MUs epi W Bre obsoWo. t 004KO rACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS <br />1. Generefor ID N -ler <br />2. Page 1 of <br />l Enagency Response Phono <br />4. Manttest Tracking Ntarrher <br />WASTEMANIFEST <br />CALOO 200 <br />, <br />14l18 -786.M5 <br />Q FLE <br />5. Generalor's Name aid Msil(Q Address C*fretatcr s Site Address (if dilferenl lion mailing addmss) <br />SW <br />5,SrSo 1� AWA <br />Stoftn� <br />Generator's Phare: $1 <br />Transporter i y Name U.S. EA ID Number <br />TMIPW Ic. C. AFMOOt 70M <br />7. Trar>$,porter 2 ConVany Name U.S. EPA 0 Number <br />2. Qfl 0- l8.3 <br />i' <br />8. Designat Facitty Nam and Silo Address U.S EPA ID Number <br />11 Wn 8 BeelNy IVV1��Dfl1QOOO <br />y <br />Fadi 's Phone: 7�%63-M <br />ga. <br />9b. U.S. DDT Desdaiption (btdu ft Proper Shippir g Name, Hazard Class, ID Number, <br />10, Cordarners <br />11. Total <br />12. Unit <br />13, Waste Codes <br />No. <br />Type <br />HM <br />and PaddrG Group Cd 8y)) <br />Quantity <br />Wt.A L <br />CNtti .DM <br />N O.S.. d A Ep1c!'�oruhr, dd0 Rep}. 9. FG ® <br />P <br />, 7 <br />E <br />ul <br />AT.OS,�i AEp�InroEgrsir� R.9.,PG R <br />OF <br />Pit <br />_ .. <br />I <br />3. <br />r <br />4. <br />t <br />i <br />j ) <br />r <br />14. Special Hardhig Instructions and Addffional hibnadon <br />Pmle,,. r t 1 S i t f1►�1� trLs e. 8' t <br />1 <br />vtt P1"t '/ <br />�b�5 <br />1xF� 0=MW57'l film tL —V©� �%�'1 d2p� r�ecj <br />(� I��� '"f -o <br />2"W, WMSiSM1106 W-- 3 G E' Y <br />15. GENERATOR'SIOFFEROR'SCERTIFICATION: (hereby decle<e that fine conten(s of consignment xe irdy and ecaaatey described above by the proper stdpphg roma, and are classified, packaged, <br />marked and labeled/placarded, and are In a8 respects in proper condition for transport according to app4 govemment ihiSons. B export stdpment and i am the Primary <br />Exporter. I cm% that the contents of tido consignment cmform to the terms of the altadied EPA grrrenl a Consent. <br />jalMKiat the waste minWmdon statement identified in 40 CFR 282.27(a) (if I am a large ituaiti stator) or (b) (if I am a 1 n alar) ss t <br />r. tame rot's dnt- r y r <br />A ki tia Lvc:�& 1��. <br />�t <br />16: ntarna Shy wwts 0 import to U:S, El Export from U.S. Pat of es xt <br />LK <br />Transporter , hors tin. s 01*): Date k-aving U.S. <br />17. TransporterAckrwAedgmerd of ReoeW MaWWs <br />Tran r yRed Name alnat ^t y <br />ITtAsporW2 <br />p L/ <br />Priqq . yped Nanatu t % y ear <br />-z <br />18. Discrp<lncy <br />18a. Discrepancy h&ation Specs El Quantity ElType ❑ Residue ❑ Partial R*don Out Rejection <br />tdardtest Referciwe Number: <br />18b. Alternate Fac illy (or Generator) U.S. EPA ID Humber <br />v <br />LL <br />Faallt '3 Plane; <br />18e Signature tri a Fac6ry(or r) Mach Day Year <br />Q� <br />Z <br />S2 <br />19. Hezardou Waste Report Mmmgement Method Cady (i.e., codes for waste beatmerd, disposal, oW re%v" systems) <br />91- <br />2. <br />A2A 1 <br />3. <br />4 <br />20. Designated Facility Owwriy.0peralor. CedRidetlon of =eipl of haratdous materials by Itre manifest except as noted in item 18a oe <br />Pr nkWTyped Name Signalure Monir Day Year <br />EPA Form s7W-V (Rev. 3-05N"MUs epi W Bre obsoWo. t 004KO rACILITY TO DESTINATION STATE (IF REQUIRED) <br />