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D i TC. <br /> C (S 41 <br /> 'tt u r�•.?.d.'. . <br /> 'Please print or type.(Form designed for use at elite(12-pitch)typewriter.) Form Approved OMBIQ <br /> P <br /> Number 2 <br /> ID N <br /> Generator enerator um . age 1%or "envy; Phone 4.Manifest Tracking Number oyngr <br /> UNIFORM HAZARDOUS 1 ; , A r•,4 ,R� nsa> , .� � . <br /> WASTE MANIFEST ',•, �,;; g <br /> 5.Generatorr sgName and Matliinngg Addrrees Generatry's:St an niaGng address) <br /> L6135 <br /> PAC=AVMUE <br /> Genereto f A <br /> 6.Transporter i Company N 77_41 14 U.S.EPA ID Number <br /> i yY <br /> t Ct• .yr <br /> 7.Transporter 2 Fri F9 U.S.EPA ID Number <br /> r *��6�47 .moi•.:, <br /> 8.Designated Facility Name and Site Address 1 d' "r " U.S.EPA 10 Number <br /> MOP <br /> PQ . <br /> ��® MOM9I 123391 <br /> D ,r�60 _ , k'4 ',Cn 54r f. .• <br /> FacilitysPhone: � � 4• <br /> n <br /> ga, 9b.U.S.DOTbescription(including Proper Shipping Name,Hazard Class,ID Number s r. i 10.Containers 11.Total `' 12.Unit <br /> HM and Packing Group(lt any)) �' xt T Quantity W Wol. 13.Waste Codes <br /> £ri t YPB <br /> r4 <br /> W X iVMW r <br /> 3:Iw tip jtr.4 k r,r r t <br /> t t s rt " <br /> 4. <br /> 4oil <br /> , <br /> 14.$pep ��� ,t ,. ♦• ' <br /> 9 pr <br /> INzu a <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby "the contents of this consignment are fully and accurately described above by the proper mg name,and are dassified;packaged; <br /> marked and labeledlpl�arded,and are in all respects in `i6mi for transport according to applicable intemational and national governmental regulations,'If export shipment and I am thd'Orimary <br /> Exp6rter,I certify that the contents of this consignment ,. .I a tennsof the attached EPAAcknciMedgment of Consent <br /> I certify that the waste minimization statement identified i' 262:27(a)(d I arra a large quantity generatorLor(b)QI1 am a small quantity generamr is true. <br /> GeneretorsfOBemr Print�Ffype�dyName / s Signature Month Day Year <br /> 0�, c9k=a, <br /> _j 16.International Shipments I to U.S. . '.f ❑ <br /> mport Export from U.S. Pat of eribylemt: <br /> z <br /> Transporter signature(forexportexports only): .r.. _ ,... . U.S.: <br /> UA 17.TransporterAcitnowledgment of Receipt of <br /> n. <br /> nsperAtlTyped jt , rv Month Day. Year <br /> � <br /> -� UP <br /> 2 Transport 2Pdn Name f f K , '019 Month b: ,.* Month Day Year <br /> /� ` � � ' 'Y '�•i, i `''rs' '� tr •� a � 4e�."y�•d}'• - � •P �1 <br /> t— v4/'4 Al i ^.4•+�t f 1 n i 9d. rl /a'+� / v <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ P,arti�Re lion. <br /> Full Rejection❑Residue <br /> ;S i. Manifest Reference Num y.`•'.r <br /> 18b.Alternate Facility(or Generator) p w.,* + t P' i Is + U.S EPA ID Number <br /> IR <br /> .C ���Svi i a i civ 'C,�, k•�,'�•ci,L� -Ci h 7r•[�;c <br /> s`Q Facility's Phone: a:S', ' ya " ' ;to,+ d;Srt. ` a�n F fir. <br /> W 18c.Signature of Altemate Facility(or Generator) ".f* �' Y; . ' 1 a :�<• Month Day Year <br /> 2 ..w •" ' •' '.' c �r. ' Vii: <br /> H19.Hazardous Waste Report Management Me6rod Codes p.a.,codes for hazardous waste treatment,disposal;and recydkg systems) <br /> G 1. 2. 4 3. 4, <br /> 20.Designated Facility Owner or Operator.Certif estion of receipi.of ous materials covered by the manifest exce in`Itein 180 <br /> Prknt�/Typed Nanre e / Signature / Month Day Year <br /> \ ! <br /> ;EPA Form 87W22(Rev.3 0 f"Prewous editions are obsolete. DESIGNATED FACILITY TO GENE ATOR STATE(IF REQUIR D) <br /> . 10297.0260 <br />