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Plea�o print or type.(Form designed(or use on elite(Q-pitch)typewriter.) Form Approved.OMB No.2050.0039 <br /> �►....� �UNIFORM HAZARDOUS of 3.Emergency Response Phone A.Manifost Tracking Numbor <br /> 1 WASTE MANIFEST i'Generator ID Number(A1ZQ0G'1AQ0t/jb! 112.Page 1 e C)c V 009506531 <br /> O 9 5 O 6 5 31 (�( <br /> 5,Gonetalor's Name and Llai!:9 Addroas Generators Sito Address(if different than marling address) <br /> {• LI P010M I) 1161)1-M (-Al? s r^/ic:4Lirl <br /> 7707 5, AV 5 r//-i 121). <br /> SrUC krai, G9, c/%o-i <br /> Generator's Phone: C/' -v -/C/o r <br /> 6.Transporter 1 Company Hame U.S.EPA ID Number <br /> itA S / <br /> Z T�anspo isr 2 Company amc U.S.EPA 1D Humber <br /> IUI r/� c A /K, <br /> 8.Designated Fac;Lly Jarre and ile Ad ress U.S.EPAID Nutt Let <br /> PCOCLA0094 Tl`�nn�% PC M6Y-1G01 Ci,A, lac' C.V, <br /> (A#tt,FC-j)./\tG:z I -r1,7L4,t1VA 140I,ill <br /> S An/ )'A 13(v, rec47r,lac 1-1(;x <br /> Fac'Lty's Phonw C%CI/- uJ i i <br /> ga, 0b.U.S.DOT Dewiption(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers It.Total 12,Unit 13 t'yasle Ccufes <br /> HM and Packing Group(,f any)) No. Type Quantity wt Not. <br /> I. L4N 199•, W A 57L FtAl 9 /}/5 C b (J 10 S, 1\1,0', y. <br /> IV,,41-/01 Sra L/7 M 9) 3, &-y 77' - U4rFi F' 3 <br /> a f 3 � f <br /> 2."N ;17. W,4S 17 !/Grp & cvivrr,9/141"(2 /ev)114tjA4 1"6- <br /> 1y 1014 PI <br /> 3. <br /> a. <br /> f_ <br /> { <br /> 14.Special Handing Instructions and Additional Information G N 7 h y TGr <br /> ti YcerUN6lol1 ,nu-,)Ai; - en- fF �7a3y/�Jonlr rs��Rl�rXI f2ctyj7e4 <br /> PAC-1S/ SOL t/G'7Vr--APP$l2/h-ytCI P.c,r�xrvu '17� rrv)r� (jl� <br /> -(4z G). u S ci It; 1&0x. x <br /> (-+S ��� to frC4/L0U(7/9y:2,7 <br /> 15 GENE ATOR'SIOFFEROR'S CERTIFICATION:i hereby declare that the cuntents of Ih'.s consignment are fuCy and acturalety described above by the proper siPpp!ng name,and are classified,packaged. <br /> marked and labeteNpiacanled.and are fn a4 respects in proper condition for lranspod accordirg to alptiwb!e inlomalional and nolioNal gorenuaontal reyuiat'ons.If export shipment and I am the Primary <br /> Exporter,i cerbly that the contents of this ccnsgnmeni conform to the terms of the attached EPAAcknrMedgmenl of Cotsonl. <br /> 1 ceddy that tile waste minimization statement idenbfed in 40 CFR 262 21(a)(d I am a large quantity generale (III am a small quantity generator)is true. <br /> Genwlor'a101terois PInWIT pe ame Igna r Month U year <br /> Wit! PC '(.s v'A42 <br /> 16.International Shipments <br /> ❑Im to U.S. { Export frcm U.S. Pod of entrylexit <br /> Transporter signature ilor ex arts oni► 1c'{ �za Date loung U.S.. G�1 <br /> pC 17.TransporteI Acknank:dgmenI of Rece:pt of Materials <br /> Transporter T PIintedlljpedName Sigrdw ant, Day War <br /> Qfans let 2 Pdnledrl)pW Nome Month way car <br /> 18.Discrepancy 11 f <br /> 18a.Discrepancy indication Space U ouanily ❑Type 0 Residue ❑Partial Re;ec6on U Ful Re'ecikn <br /> 3 <br /> Manifest Reference Number: <br /> I <br /> lab.Nternalu Faciily(or Genomter) U.S.EPA 10 Number <br /> 4 <br /> V <br /> ' ►d+• Fapld s Phone' <br /> w Idc.S gnature utNlema Fucedy(O(Generalor) I'enih Day fear <br /> z <br /> N19.Hazardous Yyame Report Management Melford Codes(i.e,.codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2 <br /> 3. d. <br /> . <br /> 20.Designated Facility Owner or Opemloc Cedlficabon of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> P,inledO)ped Name Signature Month Day Year <br /> - Y):j I(, (11r.(1r?A r l <br /> EPA Form 8700.22(Rev.3.05) Previous editions are obsolete. DESIGNATE 7 I'ACILITY TO DESTINATION STATE(it'REQUIRED) <br />