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Dec . 27 . 2019 10MAM 1 4 t No . 1437 • , P . 14
<br /> IN
<br /> IN
<br /> a8'� rhit or s. formAesigned for use qh eli(s (12-posh) tyPevrrlter,) Porion Approved, OMP No. 206A-Oa39
<br /> NII 0RM HAYAttdOUS 1 ` Generator ID Number 2. Page 1 of 3. Emergency Response Phone ' b. ah!test Trac ng umber p
<br /> WASTE MANIFEST S: ! B:: F�7') 7 3 �1Z-a� ,°1�+ 4 ° r~5 i, .• G B F
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<br /> 5. GenGIot's Name and.Malllng Address Generator's site Address ( f different than moiling address)
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<br /> Generetor's Phone: ,
<br /> 6, —Tran Ipo ar 1 Company Name U.S. EPA ID Number
<br /> ItiGtl'tie'yiGN!1010 :7:olly PC 11wr1:;P1I SimlDi?o, LINNI e1ti15�3 �t�F �� 1
<br /> 7. Traneporter 2 Company Nsm9 U.S. EPA Number
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<br /> F90111 ('s Phdne: •
<br /> 9a, gb CS 9; DOT Description (Including Proper Shlilong Name, Hazard Class,11) Number, 10. Containers 11 . Total 12, unit 19. Waste Codes
<br /> HM land Packing Group of any)) No, • Type . ouanlity W11Vol. It a
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<br /> ' 14; SpoclalNandUn¢ Ms(diotldnsaMlAddlgOnallnfofmatlon '
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<br /> Exporter, I artily that the contenfa of•Urie cone)gnmdnl cohibnn to the temia o(.IhH affached EPAActmo*49ment'of Conseril. `
<br /> t certify, that hie waste mbrimrzaUon stalembnt idenUffed ih 4g'CFR 262.27(a) (if 1 am a latge quen(Ily-genarator) or (b) (If I am a small quantity �genaralor) la true.
<br /> General s10Raror*s PUAt
<br /> Nama Signa re Month bay Year
<br /> mi % InternallonalShipments Import to U.s, ❑ Export from 111 Port or entrylexil:
<br /> Transporter slgnptgre (for exports only)f. Data laaftij U.S.:
<br /> rr 17. TransporlerAcknow)adgmentorReceipt ofMateriats
<br /> i Transpoder 1 PrintedlTyped Namb 0 Signature Month Day Year
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<br /> Transpoder 2 P *T pod Name Signature Month Day Year
<br /> 18, DlsCrapanr ( rn—�
<br /> 189. DiscraparriydndlwoonSpacAt � clpandty lJtypo ❑ Residue . L 1, PartialRejection ❑ FLIIR*4Ign
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<br /> . . Manlfesl Refe nce fiber.
<br /> 1eb. Allema a Facility (or Gedsretor) I U.S. EPA 1D Number
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<br /> u FaciYlys Phone:
<br /> w 180. s(gnaureotNtemeleFardllty (prGanetefor) Month Day Year
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<br /> 19.[HazArtlo))sN(ag>�.(te rtf n�gE' eolWth�d;4odes Q,efrbodeGfnwtW0 i ousyrastetrC2mlent, disposal: andrftycflri systems)
<br /> Qi "°'v , t t.•fig 2, k.,, ., . : a.
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<br /> A. Designated Facft Owner or Operator: Certification of receipt or hazardous materials covered by the manifest except as ed in Item 1 a �fy�
<br /> Piihl—aMped Nalne> a SIgnalurb 11 MonthDay Year
<br /> EPA Form 8700-22 gov, 8-06) Previous editi ns are obsolete. .�
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