|
Please print:or'typa.(Form desigried for use bn elite(I2•piloh)lypewriter, :Farm Approved."6yt13.No.2U5U f1p39
<br /> 9.4enerator tt]Number 2;Page'1•of. 3.:Emergena�,Resp'ense Phony 4.pAsnn{fest Trackln(pNum�ar,
<br /> i!h(IFt]R{N HAZARDOUS �+ V
<br /> WASTE NiANlFEST G f� .L]0�p 7:�3:: ; ' ��• ;-•; a: 1779
<br /> >��n
<br /> '. ,
<br /> 5: Adtliess(Ii diflarept lhaq mai{fntj address)
<br /> 84014.CtN AL AV
<br /> 0A � 3W) ilir
<br /> Generator's Phone: i.: 1
<br /> 8 T ns orkar.q Cam"e" Natrfe,i;; . 'i:''"::;r::•: ,'r;r :rsr ,;� :. ;;r�].•, vii U:S.EPAIR filum r
<br /> �15k��1�d'1•.F,�V€111►��f�llS:i�7l�il���wtz."�ir�I�r�[r�'!:�... . ..."_�..�i::;;;;;.�;;:: :irr i. ;.,. _ :� . • 1'� [x��#.'1'4�e:�i�,�. JF t�. -
<br /> 7.Transparter2,Company Nance" ' US,EPA ID Plumber
<br /> 8.Resl��a�ed Fad r*me and Site Address U.S.EPA fR IJumtiar
<br /> Y VERNON'TIC
<br /> t
<br /> 4i61 64�C�1 ,.�• t�i'+C1 t?._':1 r i3.".fJ.,�`a:� '
<br /> ' iif.f��['i; :1"' "jl� :�', ':l ift i. ,�:},;".i•.i�i r��ri i:.r:..'i f!•i ''l. ll. ::1:Ji'r:.�:::�'� ..-..M1,!1.i':::;:,i1 ..i i..•.:i.. .. ��
<br /> Faralliys Phang;. •.�:1,.?�gro 7'�-�.���•
<br /> gh.U.S.pOTDescAptlpn(Inclining Proper5liipftg Na
<br /> Cuss 1f7.{umiser. 10.Cpnlafners 31'.,Tatal;- 12:, it.
<br /> ;;; 3•Wa,te Codss
<br /> 9s: Not
<br /> FIM and Packing Group,[lf anyj� Na." Type Raarrlkty Wt.
<br /> �!i(lf�f'f t7"rt i'HAr 1 FSt111,��`Ufi"`a7 �1Ub(011:hlmb AF+."��1�'13ENT)
<br /> is
<br /> ¢I' {
<br /> 2. Ci.•i 1 dJi;?i r:;,ai:}I ::i',4!i,•Ir"., 'i,:ii:!71!:r t':L` i
<br /> 14.5 octal Eland inslmo laws and Addlitopal,IDfo
<br /> �:#Y E!;'l1is::Y C1).�1)'AC•1•.,E:1iE441xTr�i-13" ; 00 x oto 1'CR�I INAL:CERIES" WAt'GO M:"1:71:" '11ILC 0.Dal.
<br /> I P 11+ gib.s:?"43iI.P1~f J,�k43St7(7k� N °r P_4v �'-0.d549JlD f'APP.RORIATE PSRSG.�#1�t,.A()Tj=�:.1'Yg fQ.'1-P Mr.. J i
<br /> 15:. GEfVRRATQf VPFFEROR'S CERTfFICATION:I herehy_dectare I.hal the contents of.lhls consignment are fully an ac gra el ascribed above y ttie pYaparshipping twine,atrJ era clasaiflad,"packaged;, •.
<br /> madied•and IaheEerkplscerded,'and are In all respects in proper eondltlan far transport socordlag to app11ca6k fM al QtSal d anal gova enCdi regulations.If export shipment•and lam the Primary
<br /> Exdvrier,l.corllfy that the contents of chis consignment conform to the terms of the attached EPAAcknowlad nl of Cd n€ 111111
<br /> I ear5fy that•Ilii[gaslatnlnimiznllonstatement IdenBfled in 40 CFR 282.2T(a]-011 am a Iarge AuanNty ganerat o�(by"(J I an all 4 Daly goneralar)is true.
<br /> ratvdslt7ft P nl Tf Nama r�lgnstrrr ,
<br /> fvtonth. Day'. -ye
<br /> , ;. r
<br /> 16:IntarDalional Gh mems.
<br /> � Q Impart to ,S. ❑Expadlrarn U.S.•
<br /> ' Rale leaving U.B.:
<br /> Trarrspdrter.slgnature(fpr eKpods,pnikk'
<br /> 1T.Transports MA mk ti ledgm (of R0601ptof Malcuiels
<br /> y. Transporter Erks ad padt a , `•1`. Sfgnalura 'r. IAonlh Day :year 1
<br /> ��'. Y���.� � I 1.� k
<br /> Month �
<br /> v. Trsnsporler2 Pdntedgyped'Name Bipnalure Yea:
<br /> 7fia:illeerepanay Ind cellon Spare ❑ReMus ❑Parbai f;e;ecllorr "0 Full Rejeollon.:.
<br /> Quantity Typo
<br /> Manirast Rsference Number:
<br /> 18h,Alternate Fapblty(or,Genaratar) U.S:EPA 10 Number
<br /> zi
<br /> 1,
<br /> W Fa'LAI y Phony Wlonlh 17ay Yea;
<br /> 18L Signature o€Alternate Faeglly•(or.Gerteralbry
<br /> 79:Hazardous Waste Report Management Mathad Codes((.e.,Bodes for hazardous waste treatment,disposal,and reeyeftng systems}
<br /> 20.Designated Facif ty Owner or Operator:Cadlflcaven of racelpt of hazardous materials covered by t#ta{ndnilQsf except a'e noted In item.f8a '
<br /> P'0ed'D*Name Signature Month Day Y r -
<br /> #.. �`.'.� I � J EJB J I
<br /> EPA Form.87 D 22(Rev:3-q5) Pr vlo"s editions.era ahsalete.
<br /> TRANSP ORTER'S copy. .
<br /> ?
<br />
|