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., 4—vF <br />Fnrm Anr)rnved. OMB No. -2050-0039 <br />,else Ili qulqljuu lug uZel V11 re"!R im-F-4111 vFv—q.�t.1 <br />D Number E)OUS, 1. Generator I Page i of 3. Emergency Response Phone lanifest-IrrackingNumbeir <br />2. :Pg:] <br />--N GBF <br />(:fq 6 site ress (if �nerent than mailing address) <br />-Add <br />Generator's--Mme-,q g Address:r/; <br />P, R FINIEVA IG <br />A <br />MV4�'�Jo-� ®rpt M2fY <br />Qb0dratofs Phone :2AAWA1„—.v6. —;- <br />rP� jD <br />Tr—a I Company Name. <br />CALOW4 <br />s r2Company Name U.S. EPA ID Numbbr <br />8 Designated U.S. EPA ID Number <br />7�NW6.M"Sltd A*ess <br />-,wr's, <br />K" <br />hqllit's,phone: <br />9q <br />9b. U.S. DOT DescriptionDescription(including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />MM . <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />1. U G- 6, 1 L 0. S., 3, , P � q2 i <br />rv-'), UN! I,, -3,,�'VLP"J3 E- <br />011"J7, <br />00,31 <br />6`M <br />M <br />f"OUMN i—�, <br />2. <br />F, <br />4. <br />'4. Sp7la! Handlinq linstiuctiong andAdditional Information <br />15. btl\IERATOR'.StOFFERORS CERTIFICATION: I.hereby declare that the contents of this consignment are fully and accurately de6cribed above by the proper shipping name, and are classified, ed, packaged, <br />International and national regulations. If export shipment and i am the rrim6ry <br />mark6d and labeled/placarded, and are in all respects In proper condition for transport acwrdlhg to applicable governmental <br />(�4; certi�-,that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br />Exp <br />�R 20?17(a) (if I jam p large quantity gperatoo or (b) (Itl am a, mot quantity gqpeiator).js true. <br />in s <br />:mjdimI1Zati�n statement Identified I <br />the ators/04�,?ft Pr6tecirryOd-Name Sign Month Day Year <br />•� 117 <br />„� <br />fa^�ry . a ) <br />rs <br />16,16tdr6licifial Shipments <br />Import to U.S. El Export from U.S. Fort of entry/exit: <br />Transporter sigriatdre (for exports only): Date leaving U.S.: <br />LU <br />17, Tr . anspqrterAckno-wedgment of Receipt of Materials <br />Tri6 rt Pi I djThed Name 3 griature Month Day Year <br />Qa. <br />U) <br />90.6rtbr 2 Pdrited[Typed Nam Math Vay 1-Yef <br />ti <br />t <br />1B. -Discrepancy <br />fA <br />p., Discrepancy lndd@tlon Space Quantity ❑Type EResidue EPartial Rejection El Full Rejection <br />Manifest -Reference Number: <br />18b. Alternate Facility (or.'Generator), U.S. EPA ID'Nuniher <br />Uji. <br />-'SfdhgtOrelofAlt6rnateFadlity.(or-Qe <br />9, Hazardous Waste Report Management-Meth6d Codes (i.e., codes for hazardous waste treatment, disposal, -and recycling systems) <br />-21--Designated Fadlity-Ofter or Operator. Cerllficzitl(n �], of receipt of haiardoUs mateflals.cqvqrqd byyiia m�[f �xcqpWi noted in Item 18a <br />Print d/Ty 'ed Name �gn yr Month.. Day Year <br />EPA Form 8700-22 (Rev. 3-Ub) vrevious eanions are Wsolele.` <br />