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�:f+t;. �•!1?ti {�};t�fl`17 !~`';'ft�'.ir���Cr:1iN <br /> Please print or type. <br /> 1.Generalorl ;,bf Form Approved,.OMBKid,2050.0039 <br /> UNIFORM HAZARDOUS2.Page t of 3, meJJgg Resga��llsu'Pllopg 4.Manifest Tracking Number <br /> WASTS MANIFEST p?I O;7;i1111�.r"�s�J ~'G4> r —y}(afiJ~' W14142,2-- <br /> �j5.Generator's Name and MailingAddress (i+S r(, 4)x, t! t al4 r, . Generato(s Site Address(ifdifferant Ilian mails <br /> '`•(�1i»;fl�r'tC.itJ�"'� (!� r.t�1 t"�",°=''E?; <br /> 14 tjC <br /> Generator's Phone: '-'°4'a <br /> 6.Treprs�lq�t�j�o• n �}� r rM1 <br /> '' w'1 • d Y 1 ff� U:S,EPA ID Numtier <br /> 7 Transporter 2 Company Name _ f <br /> C.!.fi 1}N #iPIiE3t;ft�; F-*N I x Rt)N(t,f-'N['AL SVC', X )C`a U;S.EPA ID Number 1 <br /> B.Designated,Facility Name and Site Address I IXAN ))1ARBOR8 SPH V1.053( IUEPA Number <br /> 021 BERR'YESSA ZClr;t <br /> sm z, 'a- <br /> .E CA <br /> Facility's Phone: 1 sw <br /> ga, 9b.U.S.DOT Description(including Prop r ShTping:Nama;Hazard Glass,ID Number, 1p,Containers <br /> HM and Packing Group(if any)) 11.Total 12.Unit 13,Waste Codes <br /> No. ' Type Quantify WI.Nbl. <br /> tWt 1 }Y itilr i!L tr_ty.,'i�; + Sr tt�ty:�/�Ot,?7;�lrS rl����/�B 1'" !B0t.(L,EIV-14 � ,,, <br /> OL J` iSl1':� �ibw� 1's f�,V�L I'i Ir'f7Al I'S iJ L.rl'4 fln1f))`iwS!y 'r'�V'..{"t'?� 4'.•..3 <br /> Z 2. t G f Crt°i <br /> W <br /> 0 <br /> i <br /> 3. <br /> A. <br /> i <br /> 14.Special Handling Instructions and Additional info mesion <br /> 791719,3rnr;�, <br /> C.,,1.;n <br /> 4H� :hlE(r. r ��.€, 1 ' ""'tAined byS!1Ivy ar_tta wli 41 u <br /> LIVIr i asr r �r1r, laz s rw. <br /> 15: GENERATOR'SIDFFERDR'S CERTIFiCATIO i h reby declare that the contents of thifi i rt>7:31 ki s consignment are fully and Accurately described ge <br /> marked and la4eladlpiacardad,and are in all ra ectl in prapercondilion or transport proper snipping name,arcs arer lassi8ed pa <br /> nsport according to applicable International.and naltonal governmental regulations,If export shfpmentand I am the Primary't <br /> Exporlkr,I certify ttiai the contents of this cons lg men[conform to the farms of the attached'EPAAcknowledgment gf'Consenl. <br /> 1.carffy IkatIha:wa le minimization statement ld ntifiad in 40 CFR 262:27(x)fir I Am alarga quantity generatof)or 14((f)am a small quanUly;genarator)is true, <br /> eneraror�101fe�or's Prin Bd/Tgped Name4 <br /> �• Signature N ; <br /> Year <br /> ? / 3 <br /> t1 , <br /> � 16.Intemahona,�hipme s� nim <br /> —t � , <br /> I-1 import to U S. <br /> yQExportTransporter signfUS ; pt oCantryloxif: <br /> >< <br /> --- <br /> ate leaving U.S:; <br /> w 17LLJ .TransporterAcknovdedgmentofReceiptofMateda <br /> Transpo r dni dfTyped Name <br /> Signature ' <br /> Month Day...., Year <br /> Transporter Pr ad y** Name Signature' - ' Month Day Year <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space t--� <br /> ❑ Quantity. l 1 Type ❑Residue ❑Partial Re cellon <br /> 1 ❑Full Rejection <br /> 18b,Alternate Facility(or Generator) <br /> ManifestReferance Number: <br /> .r U.S.EPA ID Number <br /> U-- Facility's Phone; <br /> H18c,Signature otAllernate.Eacility(-Generalor) <br /> 4 Month Day Year <br /> Z � bw <br /> `19.Hazardous Waste Report tdane <br /> agement Method Cods(I.a;codes dor hazardous waste lrealmenl;disposal,and recycling systems) <br /> 2. <br /> 20.Designated Facility Ower or Operator:C011110lion o;receiPt ofhazardous materials covered by the manifest axceptas Tided in stem 18a <br /> Ll <br /> Printedrryped Name Signature <br /> Month Day Year <br /> FPA Form 83700.22(Rev.12-17L Previous editions are bsolete. <br /> J.} lYi•w�':,J;''! tit:;i :� CENERATOWNS INITIAL COPY <br />