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L .,r nn, ,. - ..,.,rP.Uyc,, -0 CY) <br /> N W <br /> W <br /> O r9 C)n <br /> N m <br /> z DA1 e�ase pnnt or type-(Form designed fir use an elite f 12-pilch)typewrite W 0 <br /> 1.Generatar m Number Form Approved.OMB No 2050-6039 <br /> rt Sl UN€EDRM HAZARDOuS .,Page i of 9 O.Emergency Response Phone 4.Manf{{['e��et Trraekinp Nu�"m,�e^^r (��/ <br /> D WASTE MANWEST 1 ,��1!1 .-.:�' i l:.,ri o U L ki SKS 1 rn <br /> S Generamr's Name.in;i h�,;d+,q 4di t C7 <br /> D Generator's Sti Address p1 different Than mailing address) _ N <br /> 0 <br /> Z (D <br /> IT 0 0 <br /> Genaretors Fbo nr C D <br /> ,,� 6.Trsnsporrerl Co•:r.r v, U.S.EPA ID Number <=3 G <br /> CD <br /> US EPAIDNumber <br /> 7 <br /> e Des,anata7 J=a..q,a!..,� i g,. , U.S.EPA ID Number O <br /> 3 <br /> S <br /> 5 `•2oliN's Ptlone: � <br /> N <br /> oa 9b L15.DOT Desop0oi)lindudmg Proper Shipping Name,Hazard OWS.ID Number, In.Conlainers I7-Tolal 12.Wit <br /> HM and Packing GmUp li(anylf Na Type Quanlily Wt.Nol, 'Neste Codes Q <br /> O <br /> o V1 <br /> a � <br /> fr <br /> z <br /> z - to <br /> w r-r <br /> rD <br /> 3 <br /> at <br /> 7 <br /> -; <br /> rD <br /> Ln <br /> O <br /> 01 <br /> is <br /> 14.Special Handling instructions and Addiffonai Information N <br /> O <br /> lD <br /> (!1 <br /> - GENERATOR's10FFEROR'S CERT[RCATION:I herebydeclare[hat the contents of this consignment are full and accurate) described atiove b the ro ei sN�m name,and are classifie1paclaged,9 Y Y Y P P PP 9 marked and labeled'placarcll and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and i am tExporter,I certify that the contents o€this consignment conform to the terms of the attached EPA Acknowledgment of Consent.I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is trueGeneralces/Offerora Prinfed'Type l Name Signature Month O <br /> is <br /> (1D <br /> J 7E.IrrEemabonalShipmenIS <br /> G <br /> Import to U.S. ❑Export from U.S, Pott lof eantrylU � <br /> Transporter signature{for exports only): Dale leaving U.S.' rD <br /> 17 TransporrerAorlowledgment of Receipt of Materials <br /> rr <br /> Transporter 1 PrintedlTyped Name Signature Month Day Year S <br /> 0 <br /> W C <br /> rt <br /> az Traasporter2PdmedTypedrdame Signature Month Day Year' � <br /> U14 <br /> 16 Discrepancy O <br /> fD <br /> 18a.Discrepancy Indication Spa ce f❑ Quantity L. Type Ll Residue ❑Partial Rejection ❑Full Rejection 0- <br /> S1 <br /> (D <br /> Manifest Reference Number: LA <br /> 18h AtIii Facil <br /> ity for Generator) U.S.EPA ID Numberr 7 <br /> !v <br /> rrt <br /> rD <br /> Fac*Vs tys Phone: Q <br /> , —h <br /> W Signalure of Aftemlale Facility(or Generator) Month Day Year n <br /> O CD <br /> O <br /> 19.Hazardous Waste Report Managemen!Method Codes h,e.,codes for hazardous waste treatment,disposal,and recycling systems) n N Q <br /> 2. 3, 4, <br /> I,Designated Facility Owner or Operator;CerG6ca&on of receipt of hazardous materials covered by the manifest except as noted In Item 18a ,13 <br /> T nredlTyped Name Signature Month Day Year Cliff <br /> O <br /> v I <br /> CO Cl) <br /> m GENERAT R'S INITIAL.COPY o <br /> rri 6700-22(Rev.3-05) Previous editions are obsolete. <br /> 0 <br />