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<br />Fort,,,, Approved. ONIB No, 2050-0039
<br />UNIFORM HAZARI DOUS iD �"`-ifn` 2. Page I a, 3. Elmner�ge!'Cy- Res -M se PhOi!6 14. Manifest Tracking Number
<br />007956586 JJK
<br />WASTE MANIFE
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<br />5 G-nelz�.,`s Name an 14.111-' Addrpss aria, 40rs
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<br />S."RAID Number
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<br />L)Esignaicrf Fac;Irry Name and Addnsz U.S. EPA ID Cdr r;ber
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<br />14. sperTaii'aandling instruc6ons and Additional information
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<br />1 GENERATOR'SIOFFEROKS CERTIFICATION. I hereby declare that the contents of this consignment are fully and accurately described above, by t e Proper Ing narnt, and are classified. package;,
<br />r , : .s if exporl shipment and I am the Primary
<br />cordingto applicable internationalandnational a a _ Ll !at0
<br />marked andlabetediplacarced. and arein all respects Ir, proper condition for transport a=ccording m
<br />Exporter, i certify that the co,tents of this consignment conform to the termc ofhe attached EPA Acknowledgment of
<br />11
<br />he waste mi, ir-nizaticn slat ment: entified, 410; CFR 2�62.27fa) I am a large quarifity geniarator! or (b) am a Small w ritty generator) _s true
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<br />Export
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<br />Transporter signature ;for exports 011',Jyl. Date ieavingU.S :
<br />1?. Transporter Ac-Nnowledgment off Receipt of Materials
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<br />.d Name Signature Mon, D Year
<br />Transporter I Printed�)Tl
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<br />Z 2 Prjrated; Tylped Name, Sig a tt u r M
<br />18. Dis!cFepancy
<br />18a Discrepancy Indi-ation S,,A.,e F-7 Partial Re
<br />I Quarittv Typpe Full Refection
<br />Re�;due
<br />Manifest RefeLn—e
<br />180. Alternate Facilit'((or Generator, U.S. EPA. 'C' Numher
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<br />Pacility's Prone:
<br />Month Day Year
<br />Pc Signature of ;tarnete Facility ,'or venerator,
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<br />19. Hazaxtis kAipste Report Manage. -Tient Metnod Codes "i,e. codes for hazardous waste treatment, disposal. and recycling - ystPm-,)
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<br />20, Designated caciiityavvncror Operator. Certification of receipt of hazardous materials covered by the man i.PS , except as noted ir. Rem 18a
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<br />EPA Form 8700-221Rev.3-05' Fp—eviousedittions are obsolete. - .0' D" t -"j
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