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<br /> Please print or type. 2 ° e Pe,5 Fenn Approved,OMB No.2050.0039
<br /> UNIFORM HAZARDOUS �er 2.Pagel o 7 Emer1 1. ?envy Response Phone 4.Manifest Tracking:Number
<br /> i,Generator ID um
<br /> WASTE MANIFEST t llwtl'JC'}; `� ,;i ??!. 3 1 f3 7r .•?p( t j'7uj 00672.4840 (1t7
<br /> 5,Generator's Name and Mailing Address I Generator's SileAddress(itdiBarontlhan maiHng,address)
<br /> C j t',C`G i-i j., Sly 131:wit ti .t:vie,
<br /> Ganeralor's Phone: ».?3'/R tf r' a I
<br /> 6.Tr�ts�gr�e��Go��rar(y Nama U.S.EPA ID Number
<br /> 7,Transporier2 Company Name U.S.EPA ID Number
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<br /> B.Designated Facility Name and 5ite.Address e'er f� I'll,RSORta 1,S)AN ,)'GK3: U.S.EPA ID Number
<br /> BERRYU13A ROAD
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<br /> Facility's Phone: Cs'i�••Il Y�,i 9-4 3 I
<br /> ga, 9b,U.S.DOT Description(including Prope Shipping Nanta,Hazard.Class,ID Number, 10.Containers it.Total f2:Unit
<br /> HM and Packing Group(if any)) No. Type Quantity 12,Unit 13,Waste Codes
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<br /> 14.Special Handling Instructions and Additional infor ation Try uj ; ^r '1313
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<br /> : 1-17 0 t,I IaKt1rl trrtitr z�: , u►;t:4ant:�c! by prioriiitror conft'r's> acta.lr��l iv h o r JI.,y
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<br /> 15. GENERATOR1SfOFFEROR'S CERTIFICATION' I herebydeclare that the contents of this consignment are fully and accurately,described above by ihe.propershipping name,and ereclassified,packaged,
<br /> marked and labelediplacarded,and are In all res acts In,proper,condition for transport according to applicable international and national governmental regulations,It export shipment and i am the Primary
<br /> Exporter,i certily that the contents of this consig ment conform to the terms of the attached EPAAcknowledgmantof Consent.
<br /> I codify that waste minimize lion statemented nlMod In 4D CFR 262,27(d)(ifi am a large quantity generator)or.1 (if,l am a:smati:quanlily generator)Is Uus;
<br /> enerato s/Otferor s P(intedlTyped Name I Signature Monlh Day Year
<br /> ,j 16.International Shipments d '}
<br /> ❑Import to U S. ❑Export from U,8. Wo ot entrylewl
<br /> Transporter signature.(for exports oniy), ! Date ieayrpg U.S:
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<br /> W 1,2 Trans 17,Transporter Acknowledgment of Receipt of Material
<br /> o po t I)Prinled/T ped Name Signature r Month Day Year
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<br /> z Transpo r2 Pr e yped Na ✓ J e
<br /> gnat bx nnih Day Yea
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<br /> 18.Discrepancy ��-
<br /> 18a.Discrepancy indication Space Ouantii ��--rr
<br /> Y El ❑Residue L_1 Partial Rejection ❑Full Rejection
<br /> Manifest Reference Number:
<br /> 18b.Alternate Facility(or Generator) U.S,BPA ID Number
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<br /> LL Facility's Phone:
<br /> w 18c.Signature of Aitemate Facility(or Generator)
<br /> 4 i ----�lnth Day Year
<br /> 19.Hazardous Waste Report Management Method Cods(i.q.,codes for hazardous waste treatment,disposal,and recyclingsystems)
<br /> 20•Designated Facility Owner or Operator:Certification raceipt of hazardous materiels covered by the manifest except as ncted in Itom lila
<br /> Printed/Typed Namo Signature : Mgnth Day Year
<br /> GPA Form 13700 22(Rev,12-17) Previous editions ar obsolete. GENERATOR'S INITIAL COPY
<br /> 1,, ,4 ,,1. r', 4'.r„'�;P5
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