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m 1 -000 <br /> v (D = VO <br /> N <br /> -0 v <br /> W (D O N G1 <br /> TI <. (D <br /> O O 1 Z) <br /> Q f cn OD <br /> O O - <br /> -- 3 <br /> Please prmt or type - <br /> UNIFORM HAZARDOUS 7.Generator ID Number i Paget d ].Ertiergen.Y 1tB'-0rxfa P" 4. raek,n9 Nurser N <br /> WASTE MANIFEST 1 012485885 F L E W <br /> 5. N <br /> Generators"me am Madny erer Add— GW,5de Addrns la 9%—A Tr maMrg ax..,, <br /> M <br /> G-1.1o,=Ph— v <br /> F TrarePima,t Company Name <br /> "urns ;Transporter2 Wmpany Name E-A 4',,tY _..- W <br /> tG A <br /> 232 B DaKnated F—hty Ni5itendtlress ,oa�-•.-. O <br /> YOf � <br /> lyde 0 <br /> oats Facility's Ph— <br /> 9, 111 U.S.DOT Desoipburr(indudirg Proper Shipping Name.Hazard Class,ID 14111 10.Containers r-,,a. 0 <br /> -- HM and P"119 G-P lit anyllNo TY <br /> 's. .-. <br /> Una <br /> O <br /> w <br /> _ w E <br /> ED 1 <br /> — <br /> 1 <br /> ta.Speaal Handling InsWchans and Addigonal Intormaflon <br /> f5- GENERATOR'SfOFFEROR'S CERTIFICATION:Ihereby dads.that the contents of this consignment arefuby and accurately described at,—by the proper shpprl name all are classrfee pa ieil. <br /> marked and labetedlptacarded,and are in all respects in proper condition for bansp iq according to applicable intematienaland national govemmental regu{anors.!f evp«t srnF+enl sd am�e P�y <br /> Exporter,I certitty that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement ident4ied in 40 1262 27(a)it I am a large quantity generator;of(b)f it l am a small quanhty gereraton is true. <br /> GeneratorslORerors Pnnted/Typed Name Signature "Gal, <br /> _ tb.Irtemagonal Shipments <br /> H ❑Impart to U.S. ❑Export from U.S. Porrofentryieud _ <br /> ? Transporter signature(for exports only): Dale Leaving U.S: <br /> cl� 17.Transporter AcknoWaclif TI of Receipt of Materials <br /> _ ya <br /> W Transported Pdntetllfyped Name Signature <br /> kill -Pa, <br /> z Transporter 2 Firintedrryped Name SignaNre <br /> F�-y lay `ea: <br /> H <br /> 18.Discrepancy <br /> 18a-Discrepancy Indication Space ❑Quantity ❑ <br /> Type ❑Resdur' ❑Peril Reffel <br /> �",A RlRi!Ayl <br /> F iib.Alternate Facility for Generator) Manliest Reference Number. `��•+ <br /> U S EPA ID Ntumpgr <br /> r+Q- Facility's Phone, <br /> Ed 18c.Signature of Altemate Facility(or Generator) <br /> Q <br /> Z fvt�tlt <br /> Y <br /> 1g.Hazardous Waste Report Management Melhad Codes fi.e.,codes for hazardous waste Imalmonk disposal,and recycling syslemsl n X <br /> L I 2. 3 C <br /> 1 D O <br /> 20.Designated Facility Owner or Operator Cedificalion of receipt of hazardous materials wvere 1 by NIa manifest except as need In Ilam 18a � <br /> PrinledlTypedName = <br /> v <br /> Signature <br /> MJnd1 V ZJ <br /> CD EPA Form87p0-22(Rev,i2-17)Previous editions are obsolete, Yea00 <br /> ' C 0 <br /> o _ G M1lTIAl C ai< v <br /> N (p W <br /> W W <br />