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v -4o <br /> ° WO CA' <br /> - r7p Plrwsu Orinl�lypa Fotrrt des rsad fr,r use ort vlihllA-pilrlrl lypeWNtw. r� � <br /> UNIFORM HAZARDOUS l C.'I Nz P F9nn Approved.OMEN.2050-0p75 CD <br /> �K WASTE MANIFEST - aAa a ar s.�*^N"P!'I't'i�a.P°.M4 PAnno ..Man .e Trac Inp NumMr <br /> ? n rn,.„r..rm.radaw,.rA«a s 4e 55 AAK 0 <br /> DaneraWYe Slla r'dtlrans(Ii tliayrenl than malllnp aad7eaal r--". <br /> Cn <br /> a Tlan�gN[ rrtaar, � <br /> U,a.Erjq lDgnpgr. 7 7 <br /> Tranyyi}Of gni rJs1.k' a 71 <br /> US EPArONe,�err, <br /> x pa,g7Mrr.v�wnv,r•M.,na car anew.. <br /> U.S EPA ID Number CD <br /> F"IYs Phone. �\ <br /> h U.S. p rlpj Shrp,ping Name.Hazard Class <br /> i*1 .IC Numpar, to.Contemers �j <br /> e+M-arR*y Group IN acyl] n Intal <br /> 12 unit 73.weals Cuaes <br /> No. Type Quantny WI NoI � <br /> 1 <br /> � ) J <br /> O <br /> f (J) <br /> or <br /> (J) <br /> /14 <br /> O <br /> C� <br /> CD <br /> C <br /> CD <br /> rd Soma!rfandlirg Inshuemrs a,-"�Add,it��ai rcrrormaaun C <br /> O <br /> *5 GENERA7DR'S/OFFEROR'S CER7fF1CATY0R:I hereby declare that the contents of this consignment are fully and accurately descrihed above by the proper shipping name,and are classified,packaged. Uq <br /> marled and Iabe ied ipla;arded,and are in all respects in proper condition for transport according to applicable international and ratio <br /> nak governmental regulations,If export shipment and 1 am Na Pnmary <br /> Exporter.I01I*that the contents of this consignment confomt to the terms of the attached EPAAcknowledgment of Consent. CD <br /> r y Mar the Nasre WWIZauon statement identified in 40 CFR 262.27(4(if 1 am a large quantity generator)or(b)(if I am a small quantity generator)is true. (D <br /> Gerreratcrrsrofbvar'st'rmtedrrypedName Signature Q_, <br /> Year (D <br /> rn <br /> � i8 tnlenlaGCndiShipments - <br /> Z T:arsppter signature(for exports only}.❑Import to U,S. ❑Export from U.S, Pant of en"lezlt: <br /> Date leaving U.S.; <br /> W "7car"Paine"Aotrtowfodgment arReceipt of Malenals O <br /> Cr 7rAnSDOrter I Prinpexf/Ty�aAfgarne <br /> MJ^� Signature Month. r Ory ,Year <br /> 4Z 7ransppger 2 Prin"hyped Mame <br /> Signature Month Day Year <br /> IF <br /> 18 Disaaparrcy n <br /> O <br /> 18a Qispeparx7 f 4_W SpaCe EJ7 puanVty ❑ `C5 <br /> Type ❑Residue ❑Partial ReleI ❑full Rejection <br /> t&f,A[81'301 y for Generator) Manifest Reference Number: <br /> j U.S.EPA 10 Numher <br /> r <br /> Fac>14ys Phone <br /> !cc Sgnature ofAttemate Faatdy fpr Generatlxl <br /> Month Day Year <br /> 15 Hazardous Waste Report Management Metflod Codes(I,e..Codes for hazardous waste treatment,disposal,and recycling systems) 0 <br /> 3. 4 cQ 0O <br /> v Q <br /> Fai Owner or Operating-Cerlifitat on of receipt of hazardous materials Covered by the manifest except as noted in Item 18a = � <br /> 1'ped Name <br /> Signature Month Day Year <br /> CD <br /> cn <br /> DO 22(Rev 3-05) Previous editions are obsolete. GENERATOR'S 1N4T1AL MCQ o <br /> CID w <br /> N <br /> 0 <br /> W <br /> ° <br /> N � <br /> (A <br />