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L –d — rV <br /> a) rV00 <br /> O CYI 01 <br /> D O fVz <br /> G) J (Z) <br /> ? ry <br /> M MAN C/]} . <br /> � Q.rralo/e -- <br /> (D <br /> ITI M CD CD <br /> I1S E I Number n !? <br /> r <br /> V9 6 win Numhuf <br /> V S EPA In Nwnb=r .�S <br /> ae O <br /> ►r A <br /> 4.mlWira Pn1W 5h#Wla Mame.Ha fd Can.10 Number. 1 o Containers 11 Total 12 Una 13 W,ivii Cb6Ba <br /> p„en Nn Tyye Ovamirry W1 NM <br /> '-S <br /> J <br /> insructh?ns and Addhoual InformMon O <br /> r--r <br /> � R p <br /> 15 TpR'S/QFFFJiOR'$CERTiFiCATtON:thereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged <br /> , <br /> marAgr and fabeledoiscarded.and are in A respects in proper condition for transport according to applicable international and natienai govemmental regulations,If export shipment and I am the Primary O <br /> Et�rpr7r I off*chat the contents of this consignment conform to the terms orthe attached EPAAcknowledgment of Consent. � <br /> tm*drat me waste mnm wDon statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(irl am a small quantity generator)is true. Month Day Year <br /> ;enerAXIADlert✓s prx wIl yped Name Signature CD(D <br /> Y t <br /> Snrprients ❑❑import to U.S. Export from U.S. Port of entrylexit: <br /> rlyparter signature(for exports only) Date leaving U.S.: <br /> Tansiticirto Acilmowiedgment of Receipt of MalOais <br /> f Prr"WT me Signature Month Day Year <br /> � yp�Na <br /> jk2 Printed:Trued Name Signature Month Day year <br /> halirabon Spm ❑ Ouan.iry EJType ❑Residue ❑Partial Rejection E Fuit Rejection <br /> Manifest Reference Number. <br /> (prGeneratar) U.S.EPA ID Number <br /> for13--tor) MOpih Clay Year <br /> Method Codes(i.e„codes for hazardous waste treatment,disposal,and recycling systems) -0 ;l <br /> 2. 3. 4 O n <br /> O <br /> v a <br /> of receipt of hazardous materials covered by the manifest except as noted in Item 1$a p <br /> Signature Month 4ay Y <br /> �J <br /> CD <br /> cn <br /> °Fee GENERATOR'S INITIAL C 4 <br /> O N <br /> �l W <br /> O <br /> Cn <br />