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Please&`nt-,r We."Furri des!cned for use on Piite 12--pitch)lype,,�,ritar) roved, No,,0!50-0039
<br /> UNYORM HAZARDOUS 1,Ger;arator 0[dumber 2-Pace of 3 Erne.rc1jer;c,,,,Response Phone 14,Manifest Tracking Number
<br /> WASTE MANIFEST 1 011392832 F L E
<br /> Gen "aro`3 Nam„,i d Mai ft,.Q Address Generator's Site Address(if differen"�an ao,ind 2dcfiess'
<br /> Generator's Phone.
<br /> sporter 1 Comoany`Jane e U S EPA D Nuin�e-
<br /> U.S.EPA ID Nurrhe�
<br /> 8.Des,mated Fac ility Name and Site Address U.S.EPA ID Number
<br /> Fadi' 1's-hone..
<br /> 90.U.S.DOT Description(induding Prope[Shipping Name,Hazarc'Class. D Number, lo.Conta:"ersVml 12
<br /> 13,',,ia&te Codes
<br /> 1 1" .Unlv
<br /> HM and,Pscking Group I V:f any)) Na. Tly.pe Qkjantlt" VV1,11vol.
<br /> 0
<br /> 2.
<br /> LU
<br /> 3.
<br /> 4.
<br /> .4.Special Handlino Instructions and Additicriat:nip matien
<br /> 15. MERATOR'SIGIFFEROR'S CERTIFICATION: I hereby-declare that the ccinments of`his consignment are fully and accurately described above by,the proper shipping name,and are class 5zd;oackaged,
<br /> rqa.;xedarid;albe'diDlacarded,and are in alit respects in properccrditiori fort,rsport accordin g ip applicable internall onal and nationai governmental regu!at,ors.if exr;oft shipment ad I a:, Priirai
<br /> Exporter,1 certi-y that the contents of this consignment conform to the terms of the attached EPA A(*nc;,,.';edgrnent of Consent.
<br /> I certify that the waste mir;4,rnization statement[dentin ed in 40 CFR 262.27(a)(if I am a large pan'thi,generator)or(b)(if I qrn a small quantity generatorl's:rue.
<br /> Ger,,er We 'Offeroeti PMnW7y*Name
<br /> Mont" D3Y 777
<br /> LJ import to U.S. Export fm U.S Port of entry/exit:
<br /> T rprist--crter signature,for exports on!'yr. Date leavinq U.S,-.
<br /> O� 17.TrDrisportei Ackrioviiedgmen'of Receipt of Material,
<br /> LU
<br /> K Transporter 1 PriiintedfTylped Name Signature Month Dav yeaz-
<br /> 0
<br /> CL
<br /> 'anspoAe,2 PninedTlyped Name Mo"t� Dep Year
<br /> 18.Discrepancy
<br /> Sa Dsgeppr-icy Indication Space
<br /> Quaritn J Type ResidueLJ P1nz E,Full Rejeciion
<br /> i�
<br /> Manifest Reference Nu[ Der:
<br /> 18b.Xtemate ity(,,r Generator' J.S.EPA ID Number
<br /> Facil.tv's Phone:
<br /> U., 18C.Signature ol'Alternate Fadlity(or Generator) 'v"ontl) Day Year
<br /> z
<br /> 9 ;Hazardous Waste Report Management Method Codes(i,e..codes for hazardouswastetreaMnent,disposal,and recycling systems)
<br /> 14
<br /> 4— —7— i
<br /> u72.
<br /> t
<br /> 70,Designated Facility G)wncr or Operator:C-edificatiGri of rece,!pt of hazardous materials covered by the manifest except as noted in Item 18a
<br /> ?rimed![voed Name Signature Moor', Day Year
<br /> EPA.Fon 871,)0-22(Rev,3-05) forevious aditloons Per,,obsolete.
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