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Nase type.(Form.designed for use onmgli(e.(12•pitch)typewriter.), Farm Approved,O5ti{6 No.205OM39. <br /> VNIFBRM HAZARDOU5 J."aneratorlD.Number 2,Page I of 3.Emer rgpesponse Phone 4,t�a hat Tracking Number' <br /> WASTE MANIFEST „ t :.`': ,w. : <br /> 5.Gsmraiols Name and Mailing Address ratbts u TePBdress(it different than mating address) <br /> 1.°Ya E 'rr*14`:s'• <br /> Gone Phone; {' + <br /> 6.Transporter Company Name` U S:'.EPAID Numtier <br /> f' <br /> 7,Transpater2 Crunparry Name Us.EPA ID Number <br /> 6.Designated Foaly Name and Site Address U S.EPA]ON umber <br /> t +. <br /> FacMI e6 Prone: <br /> ga. 9b.U.S.DDTDesaiptsol(includingProperStrippingName,Hazard Cfass,iD, TQ ber, t9.Containers it:Total, 12;1.1nit 73.Waste Codes <br /> HM and Pecking Group(if any)) <br /> Na. Typo Quantity WtNoi. <br /> W 2! <br /> (3 <br /> + <br /> 3. <br /> 4, <br /> 14.Srd'al HHyardting Instructions and Additional informatlon <br /> .} t r�lkW:,k ir1"7 -y�{-., a• u- ,�, r, ati, ,�,,;.r. - +,t, ,r <br /> 15, GENERATORVOFFERQR'S CERTIFICATION:i hereby decdare that the contents at this cmk,{nment aro fatly end accurately desrr8aed above by the ptnpar shipp#ng name,erd are classified;packaged, <br /> marked and labeladtplacarded,and are in M respects in proper condition for transport according to applicable Worpat�naland national governmental regulations.V export shipment and I am the primary <br /> Exporter,I ce*that the contents of this consignmant conform to the terms'of the attached EPAAcim Medgment of Consent. <br /> I csrtity that the waste minimization statement Identified to 40 CFR 262.27(e)Of i am a large quantity generator)or(b)of am a uanuty geherator)Is We <br /> Gererawalotferor`s Pdnfepol/F'y'p�+}�Noma Signature f ManBt; :Day Ydar <br /> w^ <br /> intaMafional Shipments fr--'ryt ... <br /> I_ !Import to U.S. ❑Export from S f ori or onVyte dt <br /> Transporter signature(for exports ONy}: �-""' Date feaving U.S.: <br /> 17 Transporter Acknowledgment of Recelpt of Mates <br /> T nsponer 1 PrintedtTpped Name ftnature Month Dap Year. <br /> t] <br /> o. a((' '� r ,- .-f1 4 r' f c�tfy/ G✓ . '� 01 .20 dr <br /> Transporter 2,PtedlPypedName Sigooture Month Day Year <br /> 16,Discrepancy <br /> 18a.Dtsaepancy Indication Space ❑ QuanBty ❑Type ❑Residue d�t Partial R*,ftr ❑Fug Rejection <br /> ManNesi Raterancu <br /> 18b.Altemato Facility(or Generator) Number, U.S.EPA ID Number <br /> V <br /> 64 Fadlys Phone: , <br /> 180,Sk datura of Artsmale Facility for Generator) MonBr Day Year <br /> 19.Hazardous Wastp Report Management Method Codes(Le.,codes V hazardous waste treatment,disposal,and recydbg systems) <br /> t. 2, 3, 4. <br /> 20,Deslgna FacflBy Qwneror opar `eriilication of receipt of hazardous materials covered by the marlbst except as noted in he lea w f <br /> Print ypa 4 igr!aUnti; <br /> 1 rX { <br /> EPA <br /> Fon 8700.22(Rev,3.05) Previous editions are obsolale. r FSA P F 'S COPY' <br />