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L Go -0 O) — <br /> D 787 s N cn <br /> OCI) Ruse prtnr or type IForm desgrexd efreraeo.l n Nhia itz.ru,:rr t i'u ter.' Famn ApPhved 011E N".1950-m'sy prt c <br /> UNIFRRM HAZARDOUS rra. f i [u,rrgsn�r Real--t'Ph— L NenIMl7raclJ Num lV <br /> Z WASTE MANIFEST 0 m <br /> s em,.r -,rn,.a<d0eg5 tIri 4It.z; t rf.� 06 342 SK5 N <br /> e-V, 51leAM—NdNbienla,an—ftQaddmes) 0 V <br /> U) <br /> D <br /> -hsv <br /> Z VS.EPA IO Number <br /> IT 0 0 <br /> _ V 5.EPA 19 Number <br /> ll2n ROPfhlt-"NTAL �Vt. INC. D <br /> C/) 9 r,esyr,an�.�-. � ..;�� V.S.EPP IO ryumher <br /> C.iEAlyllfIRE:Jk'.: 'Jr Eo d4 <br /> FVJT Tr1ryIdI JSd <br /> �xirm �.'lyL i 7 <br /> 9a - A-rra Fmper Shpt-,Name Hazard rlass.to Numb=_r l0 Gontmnerz tt.7�,at It._Inn r�,Ylaste tarries 0 <br /> HA! <br /> rye, Type �uanhty cc YJI ro 3 <br /> 0 <br /> o _ S <br /> C.itf W 5 N <br /> A1L! 0 <br /> :4LJ to <br /> SILL <br /> Ln <br /> 4 IL <br /> rD <br /> 3 <br /> ILE !y <br /> 14.Sl Randl,ng lnstructians and Additional Information <br /> 7 <br /> _ (U <br /> rn <br /> f-r <br /> -. ...-..., S <br /> GENERATOR'SIOFFEROR'S CEATIFICAT10i I hereby declare that the cbntents-of iliis[con5ignment are fu ly and`accurately e'Scnhed ahov'by-�ne'pf5pe(Shipping name,ab are cla55ifted,Ii <br /> p <br /> T.arked ana faGeled;piacarded.and are in all respects in proper condition for transport according to applicable internationaland national govemmenlal regulations-It ex4ort shipment and l am the Primary Ol <br /> Exporter,I certify that the contents of this consignment contorm to the terms of the attached EPA Acknowledgment of Consent. IZ <br /> SO <br /> I certhal the waste minimization slatement identified in 4g GFR 262.27{a)(if I am a large cil generator)or(b)(If 1 am a small qui generator}is true. <br /> tify <br /> Year W <br /> Signawre Month Day � <br /> Generator'srONero�s Prtnlad%Fyped Name IV <br /> V <br /> N <br /> j 16.International Shipments ❑Export From U.S. Pori of entrylexic � N <br /> F- ❑Import to U.S. <br /> z Transporter sionalure(far experts onlyJr E:ate leaning U.S.: <br /> 17.TransporterAckrwwledgment of Receipt of Materials Month Da Year N <br /> �. Signature y <br /> tY TranSponer i PrintedrTyped Name <br /> L-- <br /> O <br /> Month Oay Year �Si nature Transporllet2Printedlryp0:Name 9 I'D <br /> rD <br /> N <br /> 18.Discrepancy 0- <br /> 181 <br /> 181-Discrepancy Indication Space Type ❑Residue ❑Partial Rejection Full Re}ection <br /> ❑ Quantity <br /> O <br /> Manifest Reference Number', C <br /> U.S.EPA 10 Number r* <br /> fab-Alternate Facility(or Generator} v <br /> � N <br /> U 0� <br /> 7 <br /> Q Fal liry's Phone: Month Day I'D <br /> 18c SignalureofA)femaleFacility for Generator] Q- <br /> Q <br /> C <br /> I'D <br /> rn <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for <br /> hazardous waste treatment,disposal,and recycling systems} �' <br /> 1 3 d. <br /> 2. <br /> N <br /> CL <br /> 10.Designated Facility Owner or Operator:Certification of receipt of hazardousmaterials covered by the in except as noted in Item 184 Month Day - <br /> Signature — O CD <br /> Frntedl7ypadName �'rc o <br /> GENERATOR'S ININI nnO 3 <br /> orm 8100-22{Rev.3-05} Previous editions are obsolete. <br /> T <br /> 0 <br /> v <br /> to w <br /> N 00 <br /> 0 <br /> co <br /> 0 <br />