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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Faun Approved.OMB No.2050-0039
<br /> UNIFORM HAZARDOUS 1-Generator ID Number 2.Page I of 3.Emergency Response Phone 4.Manifest Tracking Number
<br /> WASTE MANIFEST rn; ,-,,`IM 71713 I _ I 1 008548522 FLE
<br /> 5 Generator's Name and Mailing Address Generator's Site Address(if different than mailing address)
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<br /> ©I'D?:;31 F G 4 1201 I 4!I`CT Prfl IP.I TVLE7 l Ali t WET 1`i,A W ST REE T
<br /> Generator's Phone: ' C!T C;5ler-,-X0?7 I RT ftir t«I- rn ."f,F-1ra;-�7
<br /> 6.Transporter 1 Company Name U.S.EPA ID Number
<br /> ctCI-iC',c?L, SJac c1t11t%, Wirt Saluitloiv Inc 1YLi9r�{
<br /> 7.Transporter 2 Company Name i pp, ^ n U.S.EPA IID Number y
<br /> 21 t�-1 ibt aKn YlA l P,J"d !F1/Xi my W. j P
<br /> 8.Designated Facility NameAnd biteAddress Gen 0 ra l 1r11'Ui(ri rlr,e el 4 fIrl t, LLC U.S.EPA ID Number
<br /> 11855 A i I i7 Rack nu.:e
<br /> Facility's Phone: 13111IEZ510138n
<br /> ga_ 9b.U.S.OOT Description(including Proper Shipping Name,Hazard Class,ID Number, 40-Containers 1111014 12 Unit 13,Waste Codes
<br /> HM and Packing Group(if any)) No. Type Quantity Wtivol
<br /> 1ifi11'�` L1+s*a lerD�al., fl: .E7ab1� ,., 1, C: !3Cd1F, f' 331 1Ti
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<br /> y 2UidirJ`)s, !n'o.tr Flasa.ahl'a liquid Tt. P. 1 Ci- Fst3s 7 f' ;3aY ll�n. `
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<br /> 311!1', b!.�sict tlt;id'i zing laquid, n. o., 1 Dr i �5r F' 1'+1 llQt?'1
<br /> (i-lvdrig en pe,,u: :de?. , i, PS II, L:Rf:;;'1407
<br /> 4CotT c;e r Llccur•artac for• R a c y r I i n r ;C.yet el E- 1 Di rlr'. : t F' ICa
<br /> Flat c�El I.
<br /> 14.Speciaf Handling Instructions and Additional Information
<br /> Liyt.id:, - L.nnscllack) 3,
<br /> i1F^2 ,ft.t.flrii;er_, Liquid •- L_ousepack; 4. lit3S':•t3(Ca}t tt.:.•r �1Nc�fa:;acc for R?C%i^1in47)
<br /> 15. GENERATOR'SICFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged,
<br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intematianal and national governmental regulations.If export shipment and I am the Primary
<br /> Exporter,I certify that the contents of this consignment oonform to the terms of the attached EPAAdmowledgment of Consent.
<br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(it f am a small quantity generator)is true,
<br /> erataralOff"ParitedliTyped Name bignature MOM Day Year
<br /> u I �� c,�.- 1 �- 1 -7c C11 I ,l-. kf',r 7
<br /> J 16.International Shipments I '
<br /> I- L1 Import to U.S.- ❑Export from U.S. Port{of etttrylexit: ._
<br /> Z Transporter signature(Ior exports only): Date leaving U.S.:
<br /> 01: 17.Transporter Acknowledgment of Receipt of Materials
<br /> Transporter 1 Printedriyped Name rgraWre _ Month Day Year
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<br /> J-Air-A rl-t �. 1
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<br /> QTransporter 2 Printedrryped Name Signature Month Day Year
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<br /> 10n1*V4PI LN1171IIRA I % 1 1 11 I"3rI
<br /> 18,Discrepancy Q
<br /> 18a.Discrepancy Indication Space El
<br /> Quantity L1 Type F]Residue ❑Partial Rejection ❑Full Rejection
<br /> Manifest Reference Number:
<br /> 18b.Allernate Facility(or Generator) U.S.EPA ID Number
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<br /> LL Facility's Phone:
<br /> w 18c.Signature of Alternate Faciity(or Generator) Month Day Year
<br /> a I I I
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<br /> 19.Hazardous Waste Report Management Method Codes(f.e.,axles for hazardous waste treatment,disposal,and recycling systems)
<br /> c .�1 1
<br /> 1 IL4 2. lqt �3 `q�
<br /> 20.Designated Faulty owner or bperator.Certification of receipt of hazardous materials covered by the manifettexcepfas noted ip'1tem"18a �1
<br /> Printe yp ame Signa re Month Day Year
<br /> / A� �t C
<br /> lI � 11-7
<br /> EPA F&I5$700-22(Rei 3-05) Previous editions are obsolete. bESiGNATED FACILITY T6E?,,ERATOR STATE(1F REOUR D)
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