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fir' <br /> Njt It G(.type.(Form designed 6.-tise of a!ta(12-pitch)typewriter.) Foan4 raved,OM$ND.2050.0039;, <br /> UNIFORM HAZARDOUS enera <br /> 1.GtorlD Number 2•Page t,oi 3 Ematgerwy Response Phone 4.fAanitestTracking Nurnhor <br /> Y ASTE MANIFEST < <br /> F a <br /> w, <br /> S.Generator's Name and Mail g Mress / t + '° r .. r "^:y'Tj3!id ratb!'s•5ita Addross(4 different then mailing address), <br /> ^I <br /> Genelaws Phone•. <br /> 0.Tratnspader i Company Name,"" U.S,EPA ID Ndmber ' <br /> 7.Transporter 2 Company Name US EPA ID Numbs( <br /> 8.DoVratad Facility Name end 5 to Address " U.S,EPA ID Number <br /> <.. <br /> FadllyePhane. '' , r '` <br /> 9a, 9r.U'S-DOT Doscxiptfon i}ndudhng Propar Shipping Name,Hazard Class,ID Numhar,: 11D Conta!ners it TaMl 12t UNU <br /> HM and Packing Group Of any)) 13:Waste Codes <br /> N0, Typn, OuaniEfy W1Nol. <br /> 1, <br /> tx 2. �� <br /> 3. - <br /> t�r <br /> 4 ' <br /> 14,Special HaC'!IN Instructions and Adddfonal Infomwtion <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this conslgnmont are fully and accurately described above by the proper sWpplpg name,and are dasshled packaged, <br /> marked and label..'placarded,and am in all respects In proper-condition for transport accattfimg to applicable International and national govenmentai tegulations,if exparEphlpmont and l sin'Iha Primary <br /> Exporter,i cadlyq hf the torrents of M consignment conform to the terms of the atts6ed EPAAduwv,tedgmorit of Co'n enl. <br /> I certify that the A4 minimization statement Identified In 40 CFR 28Y.27(s)(!f I am aisige rimlity,gonetator)o((b)Oil am a small queniity gamester)is true, <br /> Generatar'slOffames PdOWKyped Name Signa r Month Da . Year <br /> , mt1 ,+�!jP p fr f , aa r" f 7 <br /> _J 116.JntemafwnalSripments <br /> ❑Ion foU.S. <br /> pat Export from U.S. Port of entrylea <br /> 7r Wrier signature(far exports only), Data leaving U.S.: <br /> 17•TransporlarAdow4adgmenf atRece pt of Materials <br /> T dnietyTyped Name Sigoa ro . M D Year <br /> ransporter2 Prk ted>Typed Neme Signature Manu,' Day Year <br /> t8,Dkscmpancy <br /> 18a.Olsaepancy Indication Space El ck ty ❑Typo ❑ResidueFJ rt <br /> Fardel RejedJan ❑Full Rejection <br /> ManNast Refemnca Number-. <br /> iBb.Aifemate Fec7ay(or Generator) U.S.EPAID Nitmber <br /> u <br /> FadlVa Phone: <br /> 180.Signature of A!temate Fad ity(or Generator) ' <br /> Q ftamth Day Year <br /> x <br /> w19,Hazardops WaItte Report Managerriertt Method Codes VA,codas for hazardous waste treatment,disposal,and recycling systems} <br /> t, <. L <br /> 20,Designated Fa Tity Owner or Opefafoft Certification of rocs l of hazardous materlats covered by the manifest except es noted in Item 1 Aa, <br /> Printad/T Name <br /> lit" <br /> --s Mon D <br /> .�" <br /> EPA Farm 8700.22(Rev 3.05) Previous editions are obsolete, 1 RANSPOR fER'S COPY <br />