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TQ 1"ZIF GC PP W 8#12/W <br /> Pie,�se ori r type- Form ADwaM.OMB No..2050-0039 <br /> YN17CWM HAZARDOUS 4.Genertor 11)umber 2.Pags'i of: 3.Emeyeney Response Phone i MIRWK <br /> Thetift <br /> WASTE MANIFEST rcCt Is, t ,` ! r J FLGC <br /> S..Gene Na f,Ag�Addrese GetiSilbAtldtese�ifmi�remrtthan +9addreea) , <br /> 0 w W6S SAME <br /> •W�iE� <br /> t3. sporter t Company Name U, Ali}Number <br /> �ii�tfba ��leo, A Doe 9322,260 <br /> 7.Transporler2 Company Name U,S.EPA ID Ntmta <br /> 9.DesignsiIid P-adrly Name,and Site Addresa U.S.EPA ID Nc f&r <br /> is rli E#Deraw Ltic. ARD0697461$2 <br /> Faalify's Fhune: 3 � <br /> ga. 8b.U.S.DOT Dmesrai0on(mdudfng Proper ShlpOV Name,Ford Case,ID NuWw, 1& 11-71:411 Q.LM'mit <br /> 13.tNaslg Coclre <br /> HM end Pat#n9 rxauP(tarry}) No. Topa y w a <br /> l 'DF <br /> •POW . s r <br /> w 2. <br /> 3. <br /> 4. <br /> .e <br /> kamm <br /> �y e y� �ld �IrrrMnr '" <br /> int gM�i wWW oriYiiL7l o �wt II b pUirry� m47•fir»YM�fll�. R�Y <br /> €5. GENERATOR'SIQFFEROR'S CERTIFICATION: I hereby declare that the oI of this wnsignrnbad are My end arxuately deszalbed above by the proper tshWq awns.and ars gaplAsd,t 80I <br /> marked and tabatediplacarded,and are in an reapecls in proper conI top transport according to applicable intenerIIIIoneland national governmental Mgulatlow If export trl*MW aid I am•Bre Pdmmy <br /> Exporter,I certify that the contents of t•Eis consignment conkxm to the terms of the a EPA AcimwrledgmeM of Consent <br /> I certify than the urasbe mrnbni?Wn stAlemeM iderNfied in 40 CFR M27(8)(H I am a forge Cly generator)or(b)(kt am a smart 9--Oty 9 <br /> Genec*rsQftrurs PrinWypad Name -- �ra Morth Day Year <br /> s <br /> 115,I*ftma%orial SNpraph (�r <br /> LJ Import to US. ❑upon f.U.S. Phrt d <br /> g Transpoew signature(!or exports sly): U.S.: <br /> 47.TraneporlarArim mvfedgment 61 of Materials <br /> Transporter€Prfnladliyped Namb SmQnnlrne Madly. Day Year <br /> Transpratar 2 Fdntadliyped Nannie Signatmn M Year <br /> iB.Dureparmcy <br /> 1 Be.Discrepancy!nd1caI Space 1-1 Quantity O Type ❑Residue Q Partial Raj KWr, ❑Full Rejection <br /> Marmdesi Reference Number: <br /> fBb.Aitematp Forty(ar Generator) U.S.EPA 10 Numper <br /> V <br /> Faplity`s Phone; <br /> W 18c.$gmtitrlre.ofAftTweFac3Aty(Of GaI Month pay Year <br /> 14.Haardous We3to Report Marmagemerd AAethod Codes(.e.,codes far hazardous mwte treatment,dlcpGaal,and racyclrmg systems) <br /> Lu <br /> 1. <br /> T <br /> 3. 4. <br /> 20,Designated FadI ty Owner or Op erabr:Cer tet on of receipt of hezardorrs matarlels covered by 4ie rnwftt except as octad Ir llsrn lea <br /> [P=y �na�rMI Day Yaw <br /> 03 J-dI <br /> EPAFo obode <br /> � �fiar.�d �Ivawprt� ee ' �►r iG�ar���ac��« o��� oR <br />