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L -0 O) N <br /> Cl) N N <br /> 0 Please pant or pe,(Form desrgoed for use on elite 112-Pdch7 pewdten) pprova O O <br /> z UNIFORM HAZARDOUS 1 Generarw 10 N.mtwr p Pa e r Farm a d Ofh`�nn 2U50-OU19 N <br /> WASTE pe <br /> 9 0l 3.Emergnncv Rxspnnse vbrme 4.ta.mleer Trackrnq Number {y •• O <br /> D 5.Gene+aro'=Name and Manma Address 3U T O <br /> Ceneramr's Sita Mltlms,Ur d,ff nl than mell'mg a6tlres�1 1n <br /> D o m <br /> zGenerator's Phone 3 <br /> 6.Transppter r Conrpan�Nn���r (p <br /> Ill U S.EPA ID Number <br /> `.T nayMer_G•�ry env lr_n r: N G <br /> U.S.EPA 11)Numher ly (D <br /> 8.o9soynarEJ F,>,�i•t.N�nz�n,i tiin�4,ltlrex� 11.9.EPA 10 Numbef O <br /> Fe lrry's Phwre: ,. � <br /> f ga 9b.U.S.p0T Des.n000a r�ncladuru Frnper Shipping Name,Hazard Class Il)Number, t - N <br /> It <br /> kM and FaeAr.�u•-roue rr ani 11 �,Containers 11 Total 12,LLml 13.Waste Codes (D <br /> No. Type CuaMlly WLNW. <br /> !Y <br /> a 3_ <br /> LU <br /> W r�F <br /> 3. 00 <br /> I-� <br /> V <br /> O <br /> W <br /> n N <br /> V <br /> T4 Special Handling nstmceons and Additional Informal 0 <br /> ((D <br /> I G <br /> (D <br /> Q <br /> 15 GENERATOR'SlOFFEROR'S CERTIALATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are dassrtien,packagM, <br /> marked and label cllplacarded,andare in all respects rn proper col for transport according to applicable inlemabonal and national governmental regulatons.11 expottshipment and I am the Primary <br /> Ex)orter,I certify thar the contents of this consignment conform to the temts of the attached EPAAcknowledgmenl of Consent. r+ <br /> cerlify Char the watts minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)fill am a small gbanUty generator)is true. S <br /> Genemtor'sr0llerors Pnnted/Typed Name Signature Month Day Year 0 <br /> rrt <br /> ..a }6,Mtema[ronalShipmenfs <br /> z <br /> L:7 Import b U.S. ❑Export from U.S. Port of entryfaxh, Q- <br /> Transporter signature(for exports only): Date leaving U.S.. Ln <br /> LLI 117.TransporterAcknowfedg",,I of Receipt of Materials D4 <br /> O transporter t Prinledr7yped Mame Signature Mont, Day Yeat. rt <br /> 6 <br /> N N <br /> Q <br /> QTrarlsporler 2 PrintedrTyped Name Signature Month Day Y (7) <br /> 18.Discrepancy <br /> 18a-Discrepancy Indil Space <br /> ❑ Ouantiry ❑Type Residue Partial Rejection []Full Rejection <br /> 18b.Alternate Facl(or Generator) Manifest Reference Number: <br /> � U.S.EPA ID Number <br /> U <br /> Fal Phone. <br /> w18c.Signature of Alternate FaciFrty(or Generator) <br /> Month Day Yet <br /> � <br /> z <br /> y19 Hazardous Waste Report Management Method Lades{l,e_.codes for hazardous waste treatment,disposal,and recycling systems) <br /> D 2. 3. 4. <br /> O CD <br /> C4 n <br /> 20.Designated FaWdy Owner of Operator_Cero ation of receipt of hazardous materials covered by the manifest except as noted in Item 189 O <br /> Pdnled(Tv <br /> yped Name Signature Moth pay Year <br /> 2 �k <br /> EPA Form 870022(Rev.3-051 Previous editions are absalele. GENERATOR'S INITIAL.COP <br /> O <br /> v � W <br /> (Q r� <br /> N � <br /> O <br /> W <br /> O <br />