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L –0 CY) <br /> 0 N Cr <br /> Q O se (r <br /> Z om <br /> G1 u' No <br /> D Form Approved-OMEN..2050-0039Cn <br /> D +Tease Oa,rwas IFormcl-anedteruseoneliteli <br /> --prtch)IvnewhteGl Ti Cn <br /> z UFORM N <br /> 1.Gen£dtnr In N.mb£r <br /> NIAZARII =Prge 1 of �.Emergency Resp.n6e RMnn F LE <br /> WASTE MANWEST <br /> 5.cn�erarera Noma and nlading Admess Gen©ratofs SIM (U <br /> Address pl difl.rent than mainny addres•.f <br /> m o 0 <br /> _ D <br /> cn ' < <br /> Rh— US EPA Ie Numtei O*Q <br /> ranstxnner 1 W"4.— <br /> 7.Tra>•s�t, c mi N,iin. <br /> ,is,EPA 10 1 <br /> RI til <br /> a.eeWnated Fedgy Name and Ste Address V.S.EPA IO Numher <br /> 3 <br /> S <br /> v <br /> N <br /> Faceop s Panne. pr <br /> 9a <br /> 9b a S.DOTrJescdDtion pncludirg Proper Shipping Name,Hazard Class.10 Number, 10.Canlainers 11.Talar 12.Unit 13.wast.codes � <br /> No- Typa Ouannty wI NN. Q <br /> HM andpR�k:nc7l'•rL'UPIlranylV <br /> 0 <br /> O CC <br /> 4 < <br /> C � <br /> W <br /> 2 1 r�P <br /> CW7 <br /> In <br /> ...E7' LA <br /> O <br /> N <br /> 14 Special Handling Instructions and Additional Information - 00 <br /> V <br /> F� <br /> W <br /> T1 <br /> In GENERATOR'S10FFEROR'S CERTIFICAYION:I hereby declare that the contents of this consignment are fuNy and accurately described above n the proper shippingItex name,and are cVassm lh packaged' r <br /> marked and labeted,placarded,and are in all respects in proper condition for transport according to applicable international and national governmental reguVatlons-If export shipment and 1 am the Primary M <br /> Eiipwter.I Certify that the contents of this consignment conform to the leans of the attached EPA Acknowledgment of Consent, C <br /> I certify that the waste minimization statement identified In 40 CFR 262 27(a)(d I am a large quantity generator)or(I lit I am a small quantity generator)Isi un. ey ear < <br /> gra ore v <br /> Generales! erors rieled,Typed Name 0 <br /> ' O <br /> tT <br /> 15.InlemalienalShipments ❑ExponfmmU.S. PortoleniryfexiC _ t^ <br /> ❑Import to U,S. (D <br /> z pate leavin U.S.: <br /> Transporter Signature{for e>t ods orf): <br /> ar <br /> [X 17 TransporterAckroWedgmenl of Receipt of Materials h onih gay YeQ <br /> ignature <br /> >— Transporter 7 Prinled/Typed Name <br /> p Month Day Year r-f <br /> a Signature S <br /> z Transpoher2 Printed(ryped Name O <br /> C: <br /> r•I <br /> 18 Discrepancy ❑FoilReIeclion to <br /> 189-Discrepancy Indication Space ❑ ]uantity ElType ❑Residue <br /> ❑Partial Rejection <br /> fD <br /> Manifest Reference Number. Q- <br /> IJS EPA In Number Q <br /> fD <br /> 18b.Alternate Faolq for Generator) to <br /> OU <br /> J � <br /> tj Month Day `fear N <br /> Ith <br /> I Facilll's Phone.o I <br /> i8c,Signature olAltemate Faality for Generator) Q <br /> W <br /> a <br /> �] <br /> CD 19.Hazardous Waste Report Management Method Codes(I e.codes for hazardous waste treatment,disposal,and recycling systems) cD <br /> 3. r=-r� (� <br /> Q i n EL <br /> rtwn of receipt of hazardous materials covered by the manifest except as noted in Item M18a Month pay <br /> Year, <br /> fr 2Q,Designated Facility towner ar Operalor.Cerfiika Signature _ <br /> Printed1T-Yi Name �p <br /> GENERATOR'S"TtALCOP o <br /> m 1 <br /> us editions are obsolete. <br /> cn Cl) <br /> � A Form 8700-22{Reu.3;Q5}-Pry 00 <br /> O <br /> rs <br /> 0 <br />