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M m -UO0 <br /> U 2 - 0 <br /> Z DNo � v <br /> v � o0N' G� <br /> -n =3 ao C:) m <br /> c <br /> D sv <br /> m <br /> C)7 0_ v <br /> E N N fE ;I IIIc t o <br /> M Please print ortypeIII III III N��I III ... <br /> I..tl iNil&{ O w <br /> = UNIFORM HAZARDOUS 1 Generator l0 Numher ?Pegs 1 of a Eme Farm proved.UM8 rr<, i�5r;�p�:;; <br /> (r <br /> rgerwy ReeponAe Phnrie t.Mm Nr r 1 anrhM N <br /> (n WASTE MANIFEST 0��^y +O��O ��� D <br /> 5.Generator's Ndme and Mailing Address venerators 511e Address UI dleeroM man matting addreul 11 �] O Cl) <br /> � <O <br /> t CD <br /> Generator's Phone' t't G <br /> 6.Transnoder 1 Company Name - v N <br /> W t EPA IDNumbn C)O W <br /> ZT <br /> 7.Transporter 2 Company NameID" CA) p QJ <br /> U FA S Ezzm, v 0 CD <br /> B.Designated facility Name antl Site Address U5 FPAIDNamr- C <br /> Q QJ <br /> Facility's Phone- D CD (n <br /> ga 9b.U S COT Nscnptron(induding Proper Shipping Na".Hazard Class,ID Number, 10,Containere 11.Total 12 UMI O 3 O <br /> d NM and Par6my Group lifanyl) <br /> Type Ouanbfy mr"d '�PJeslr'. C:) <br /> = <br /> o w 0 <br /> w /�� <br /> 2 2 <br /> C1:4) l <br /> ' t v D <br /> I <br /> _ CD <br /> J - C) <br /> L <br /> v <br /> a M n <br /> �I O <br /> w 3 <br /> CO-0 <br /> N �p <br /> 14 S,erialHandling irtsWcdonsandAdditionallnformalion v � <br /> 00 <br /> O 7 <br /> 15. GENERATOR'SIOIFFEROR'S CERTIFICATION:I hereby declare that the...ants of this consignment are fully and accurately described above by thepropershi <br /> j marked and labeledlplacarded,and are in alt respects in proper condition for transport according to applicable mtemalional and national governmental r lans.if export � � <br /> Exporter.I cemty that the contents of this consignment conform to me terms of the attached EPA Acknowledgment of Consent. g p�shipment and am the Primary CD <br /> 1 certify mal the waste minimization statement identified in 40 CFR 262.211a tf I am a lar a uantil enerator or i1I am a a It uartl <br /> ( 9 q Y 9 1 1 1 1 q ry generetaQ e'. CD <br /> Generator'slOPeror's PrinleciTyped Name Signature <br /> J 16-Intemabonal Shipmenls ❑ <br /> i Import m U.S. ❑Export Irom U.5 -` Port of entrylexit: C__——- m <br /> Transporter signature(for exports only). Date laavtng U.S.. M <br /> Cr17ranspw{ergcknowledgment.(ReceiplofMaterialsD <br /> wsporter 1 Phnledlryped Name Siynalure in,.nmDay zeaO <br /> Qporter 2 PonledRyped Name Signature rAcmtf, pay y'ew <br /> 3 <br /> 18,Discrepancy 07 <br /> 19a.Discrepancy Indication Space <br /> ❑ <br /> Quantity ❑Type ❑Rnsuo re ❑Pamel RepcW ❑Fuu kP.,. D <br /> Manifest Reh,ii,-Nwnbnr � <br /> F lab.Alternate Facility,to Generatorr US EPA ID Numher O <br /> J O <br /> N <br /> v <br /> LL Faalrty's Ptrorle; 00 <br /> f$C.Sgnature of Alternate Facility for Generalorl Monts Dav <br /> Z W <br /> ty 11azwdous Waste Report Management f*Itad Codes(i e„codes far hazardous wase treatmentdisposal,and lecycling systems) _ <br /> p 7 0 <br /> n x <br /> (D <br /> Is' rated Faab*. C)Pe pl. < 0 <br /> Desrg y Owner a rata;uMcauan of revel f nazardnus materials covered by me mantles!except na0ed m IMm 18. CD O <br /> Pm'ladffyW Nam Signature zea, 71 D Q <br /> EPA Foarrrt 87W22{Rev 12.17)Previous edtiwns are obrsuiete GENERATOR'S INITIAL COPY cn N � <br /> v � o <br /> Cil <br /> N �a:^ _ v <br /> C;1 m v <br />