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Tease print or type.(Form designed for use an eliteitch 12- 0 0 5 1 3 5 8 2 1 S K S <br /> ( P )typewriter.) Form Approved,OMB No.2050-W3S <br /> UNlFORN1 HAZARDOUS 1 Genera€or It]Nurntyer 2.Page i of 3.Emergency Response Pltgne 4,Manifest Tracking um <br /> WASTE MANIFEST 006136821 SKS <br /> Generators Name and Ma ngAddress GenaratpI Srte Address(if aifierent than ma ling address) <br /> Generatci'sPhone! i , * <br /> 6.Tran�ortar 1 Con�yn,T Name • <br /> J.S.EPA ID Number <br /> 777n£nspcmt t-2 Carr�any Name <br /> V.S.EPAID Vumter <br /> S.Dt sgnated Fat Naim atance and S4e Aditss <br /> U.S.EPA ID tiumDur <br /> Fackily's Phone: <br /> 9a 9b.J3.DOT Description Ping Frog Shipping Name.Hazard Cass,ID Number. 10.Containers <br /> HM and Packing Group(if any)) 11.Totat 12.01 4 13.1Yaste Codes <br /> t. <br /> No. Type Quantity WtNol. <br /> w <br /> z 2 <br /> int-1£t r 4 ; 00 TS W 1-1�R 2'of <br /> 3, <br /> 4 <br /> i <br /> t <br /> ?.Specie Handling inst11 C':ians and Acdtonal IntOrmaUon <br /> TF1, � <br /> gar <br /> t 5. GENERATOR'S)GFFEROR'S CERTIFICATION: I hereby ceciare!hal the contents of hs wrsignntent are fully and accurate€yrloscribad above b the r so i. name,atd are dass5e�1. acic d. <br /> rnarkax#and labelediplacarded,and are in all res is in r y P°� PP� P <br /> p� P> conditien for tansport according t-applicable it Iemati I and national govemmentat regutatiosts.l'export sh purer t arid!am the Pnrr cry <br /> Expo ter,f cosi y that he contents of Urs consignment gNifq{m to the terms of We ailached EPAACfinmledgment of Consent. <br /> eertify t4at Ihq waste mirmization statement iderUUad in d0 CFR 252.27(a)of!am a targe quantity genera!or)pr fb);f t am a small quanfiiy generator)is true. <br /> GeneratorsifXferorsPrintedfTypedName Sgneuru Mantle Day Year <br /> � ?o.intemafi<;ral ipmenis n I� <br /> I.poll to U,S. <br /> z Transporter signature{for exports on i J ExPcrt fro r U.S. k"efa xr <br /> pate leavinging UU.S.: <br /> .r.Yrar portarAc ufxvledgrnept ct Receipt of kia%nals <br /> T .s er?Pr,Modr' Nance <br /> a Sgnau re tr3rMtth Day Year <br /> 0 <br /> Q Tans 2 r5ledfTpedNatrP Signature <br /> 6tonth Day Year <br /> 16.Di ctepancy <br /> 18a Discrepancy Indicalwn Space <br /> LJ Quantity Type ❑Residue ❑Parliat Resection ❑Ful Re-ection <br /> EAanifest Reference N!:mber- <br /> ?&h.Alternate fap�ty Iry Gene€ator) U.S.EPA l0 Numbef <br /> ) <br /> UU Facili!Vsphone <br /> iSe 3gnat�reofAttemAisFac:UtylnrGenerator) on Day Year <br /> z <br /> 19.Hazardeus aYaste R=pnrt h?anagemegt P tethod Codes{i. .,codes Por hazerdrats waste treatment.disposal-arml recycl ng systems) <br /> Lam'] t 2, 3. E. <br /> Designated Facsl:ty t}xner w Operaku:Certf lion 41 <br /> re080t of hazardous Mt-nafs covered by the rnanit6stocep[as msec is Item tea <br /> Pri Typed Hartle -. Sic aiu MaMft �, ear <br /> r <br /> EPAFnrma7oa-2 { v. Q ) re editionsale ofete. DESIG A ED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />