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.ter— 'q'qtt NN NNNNJgq� <br /> 006136621SKS <br /> Please print or type.(Form de red for use on ehle(12-pitch)typewriter) Farm Appmved.OMS No.2056+7039 <br /> 1.Oemrelar lD Number 2.Page 1of 3.Ems Response P d. anlfwlTradkin Nuabr <br /> UNIFORM HAZARDOUS ° 0 0 61 6 8 21 SKS <br /> WASTE MANIFEST <br /> .Ger mums Name end MaNn9Address GaremWS Sib Assess(it different than rreil ng address) <br /> C mmug's Phone: <br /> B.Transports,1 Company.ams U.S.EPA ID Number <br /> 7.Tmnspoda 2 Cwpm y Name U.S.EPA IO Number <br /> B.Desgnaed Faced Name and SAeAddrass U.S.EPA ID Number <br /> Fart( 's Plbna: <br /> 9, 9b.U.S.DOTOasa"m(in dudslg Pbpet Shlppag Nerve.Hazard Clan,10 Numberr, 70.Conleecem11.Tow 12.Una 13.Waste Codes <br /> HM and Paddng GrouP(darg1) No. Type Quarriry WWa. <br /> 1 t <br /> O <br /> w2 <br /> 3. <br /> 4 <br /> i <br /> '4.Spacga"Handing lnstmc' s andAdQlionel lnfurma(ron .. _ . ..,,.. . ._ <br /> i� b <br /> ir <br /> 15. GENERATOR'MFFERORSCERTIFICATN)N:Thereby dedare hat the csnlenbs o/tlw oonUg,ment are hly aNacaeately deaobeE afpve br'dre propmshgpeg wine,and aratlaasEetl.parted, <br /> maMed aN labekWplacxrded,and min as respeps in prom WrWitim W tra,sFat acwdng to applimde hemalionmeld natIorel govemmeael r <br /> e9Wetlons BexpM anpmaM.and jam IN Pnmary <br /> Export,I certlfy Bal Na wmenis aavimnsignmenl dmtonn b rhe terms of Ore atletrN FPAAcknordetlgmert of Concent. <br /> I cemly tretme waste m n-41409br statement IdemW n 40 CFR 20227(a)(0I am a large quan5ly ge mv)or(b)(dl am a wal qumey geriimis)is tree. <br /> Gerbrabl'sIOEMoys m"Name Sgnalure <br /> Mash Day. Year <br /> 4 z 7 <br /> lu.1Aembora pms,6 <br /> a ❑Import to U.S. ❑Fxpon,Iran U.S. Pal of'try(md[__ <br /> Transporair sgrabre(for exports onry) Dale baring U.S.: <br /> +.?.TrenarnderAAmadsagnls4r:of RacW dMrirwls <br /> y. <br /> if 5 r 1 Pdrged% Name Signature paltry 0a Y <br /> rang 2 IB0/7`'pN Noma SgnaNre r A N bay Year <br /> a <br /> t78,Dauapancy <br /> 18a.Discrepancy lnkadion Spars ❑ Quarto ❑Type [-1 Resew ❑Penal Rgpmm ❑Pot Ru jaaim <br /> McNfesl Reference Number. <br /> 18b.Alternate Facility laGererabr) U.S.EPA ID Number <br /> J <br /> U <br /> u Fiiaq+s Pham, <br /> y9 ten.Sgnawm of mammmm Fadlity(or Generebr) Alonh Day Vear <br /> z <br /> 19.Hazardous Weiler RePW ManegemenlMOW Codes g.e..codes for ha pirdatswaste Vesso mt,disposal.and,.q t'ng systems) <br /> D 12, 3, 4. <br /> .Designated FadAy Otmer Of Operator:Ce Padua dreoWof hamrdoua m*dals ooverN by hs rr®ngfst ex CM as rated in liam lea <br /> P Name S Mash Day Year <br /> EPA Form 8709.2k4 e. edm are. _ ate. DESIG A ED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />