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Please print or We (Form designed for use on elite (12 -patch) ) <br />0 Form Approved 0 21)50-Od39 <br />EPA Form 87tH} -22 (Rev 3-05) Previous editions are obsolete DESIGNATED FACILITY TO DESTINATION STATE (tF REQUIRED) <br />UNIFORM HAZARDOUS 9 Generator 10 Number <br />2 Page 1 of <br />3 Emergency Response Ptwne <br />4 infest Tracking Number <br />WASTE MANIFEST <br />9 <br />I-8W1W7= <br />0080 <br />L, <br />Generatoes Name and Mailing Address Generator's Site Address (it different them mailing ) <br />AFFIX TO RIGHT SIDE <br />n To AIM. SI <br />51$ s <br />OF ALL HAZARDOUS <br />SWddM CA OM <br />MATERIALS BILLS AT jr <br />Generator's Phone W6286M <br />$D TAB WILL STIC <br />rartsportar 1 <br />U S EPA ID Ntmrber <br />"AVAe ra c t.A®E6 h aoa <br />7 Transporter 2 Company Ham <br />US EPA ID Number <br />8 Designated Fwdq Name and Site Address <br />US EPA ID Number <br />MCP <br />Facility's Phone <br />98 <br />1 9b U S DDT DescnpWn (inchidrrg Proper Shipping Name Hazard pass, ID Number <br />10 Containers <br />11 Total <br />12 Unit <br />13 Waste Codas <br />No <br />Type <br />HM <br />and Packing Grasp (it any)) <br />Quantity <br />Wim <br />19 <br />9B9 <br />,O <br />a <br />X <br />Cr— <br />OROP <br />2 <br />w <br />t,9 <br />3 <br />4 <br />14 Special Handling hts%udrons and Additional Information <br />9 I 7(�xC <br />15 GENERATOR'SIOFFERDR'S CERTW-ICATION i hereby declare that the stents of this consignment are fully and accuratelyr described above by Bre proper stappsg name, and are classified packaged, <br />marked and placarded, and are m all respects in proper condition for transport aocordmg to air mina ori"g�ovemme,,IWMgulakors h export shq�men4 and I am the Primary <br />ceAfy that the contents of thiscore inmentcaitorm to the temts of theattached EPAAdm mart aCon 11191 <br />certifythe waste mean eta t rdentdled m 40 CFR 282 27(a) (it I am a large quantity ta} or (b) (6I <br />is true <br />Gerrerata a reLkinth <br />uayear <br />e <br />40 1 1i'l�.,s' <br />lrtcport to U ❑Export from U S Pat of entry/e <br />Transpoft Irature for ex Date kasvirig U S <br />17 TranspoduAdmow t of Recept of VaWels <br />ransporter 1 FRmtedrryped Name re <br />y ear <br />/on <br />+ <br />Transporter 2 PnnfbdfTyped Name 0 Signature <br />Month Uay Year <br />18 Discrepancy <br />18a Discrepancy Indication Space ❑ Duenbty ❑ Type ❑ Residue <br />❑ Partial R%eceon <br />❑ Full RelecAon <br />Manifest Reference Number <br />18b Alternate Facery, (or Generator) <br />US CEPA ID Number <br />J <br />�- <br />Facilo Phone <br />�j <br />18c Signalise of Altemate Facility (or nemkit) <br />Month Day Yea <br />d <br />2 <br />19 Hazardous Waste Report Management Method Codes (r a codes for hazardous waste beatment disposal, and recycling systems) <br />Q <br />1 f t I `r I <br />2 <br />3 <br />4 <br />20 Designated Facility Owner or Operator Cerhrcabon of reoerpt of hazardous materials covered by #* manfestexceptas rded in hem 18a <br />Pnn yped Name L6 Signature <br />Morm Year <br />EPA Form 87tH} -22 (Rev 3-05) Previous editions are obsolete DESIGNATED FACILITY TO DESTINATION STATE (tF REQUIRED) <br />