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L -0 or) <br /> N <br /> rt Cr <br /> OQ0 Cn <br /> OPlease print or type-(Form designed for use on eFle t12-pilchl Ivpewdler.) Fnrm Approved,OMB Na,205p-Op39 O O m <br /> UNIFORM HAIAi S 10anemiar ID Number 7 Page 1 of 3.1:tte en[v Res Fh.�na. !.Manll=s N <br /> WASTE `� crnso iTrzcHngNomhe. .. O CD <br /> D SKS 0 <br /> 'fenaraorls Nams an6 n1alhng AdtlRss ,. :;n-Arlans�rd Jou.:--nunae ma�4na�n3res, 0 <br /> z Q Q" <br /> CD <br /> IT nt- U...EPA 1D Numbbr < 0 <br /> IV S.EPA ID Number 3 <br /> S Dei-J��i.iia.==a:�.�.:�ry._�..:�� � .. -� U.S.EPA 40 Nun,bF, � <br /> O <br /> Fa;i14Vs Pr,ene 3 <br /> 9a 9r USDDT�eSrnplrY' -:':1n]Proper Sh,ppiny Name.H—d Class.ID Number. IO.Containers n r. ,1 12.Unit 13.Wasle Godes <br /> HM ann Faux r_r,r;op nr a-;•• No, 71pe19 <br /> Bmf �N1.Nof. N <br /> O Q- <br /> O <br /> cau" V1 <br /> W <br /> 0 08rn <br /> 1 13 0 16= rrt <br /> 7 I'DDili16 , <br /> 0 v <br /> 0542r fD <br /> 00:* In <br /> 14.Spacral Handling InstruCill and 72 O <br /> O <br /> 977 01 <br /> 6Bs H` <br /> :5. GENERATOR'S10FFEROR'S CERTIFICATION_I hby declare That the contents of this consignment are rally and accurately described above by the proper shipping name,ant are c1055ifie1 112=11. -r3 VI <br /> marked and labeled,placarded,and are in all respecls in proper condilion for transport according to applicable inlemaGonal and national governmental regutationsSrexport shipment and l am the P+imary VI <br /> V <br /> Exporter,I certify the contents of[his consignment confarm to the terms of ft attached EPA Acknowledgment of Consent, N <br /> I Certify that the waste minimization statement iden[iRed in 4i]CFR 262.27( Signature a)lit I ams large quaff generator)or{bl(if I am a small quantity generator)is Vue. Month Day Year :013 7Z <br /> N <br /> Generawl5,'Cmemys Printedfr-M Name <br /> v 3601 N <br /> 16 international Shipments ❑Export from U.S. Port of entrylexiC q 021' un <br /> ❑Import to U-S. p q - O <br /> z Date leaving U.S.: <br /> Transporter signature(!or expmis only7: <br /> 0 rn <br /> 17.TminsporlerArkrtrnviedgmentofReceiptofMaterials Month Day Year 0 CD <br /> Signature G <br /> Transporter'!PrimedrTypad Name q <br /> N <br /> Month Day Year p <br /> Q <br /> i Signature <br /> Transporter 2Arin[edliypedName 0 <br /> t r+ <br /> S <br /> ❑ <br /> O FuIJ Reiactlon O <br /> f8.Discrepancy <br /> ❑Residue ❑Fartial Re}ection r* <br /> lea.DLwnapancy frKhcascrn Space ❑ Quamily ❑Type cU <br /> LA. <br /> Manifest Reference Number: l7q <br /> S.EPA ID Number 7 <br /> CD <br /> 18b Altemate Facility(or Generaloq 0- <br /> 0- <br /> Month <br /> QMonth Day Year ` N <br /> =acif l Phone' Oq <br /> 8c Signature ofAltemale,Facility for Generator( 7 <br /> l � <br /> r-r <br /> Mana emenl FAetri Codes fi.e.,codes for hazardous waste treatment,disposal,and recycling systems) Q <br /> 3.fiazardDlJs Waste Report g 3 --h <br /> 7. <br /> O N <br /> MOnlh Day Year ? (Q O <br /> peaignaled Facility Owner or Operator Cer6�ralion of receipt DI hazardous materials covered by the manill 5 gnat eCep!as noted in Item 19a N <br /> ntedlTypeQ Name s <br /> GENERATOR'S INITIAL COPY _ <br /> evious edfiions are Obsolete. <br /> O <br /> T cn <br /> v <br /> rn w <br /> m w <br /> O <br /> O <br /> co <br />