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<br /> Plea;s.p(Ini or type, Form Approved.OMB No:2050.0039
<br /> UNIFORM HA7ARDOUS 1.Generator i Nunitrar 2,Pago 1 of 3,Emergency Response Phone 4.Manifest Trackin Number
<br /> e WAS MANIFEST CA!id"il,11If48 3 t.) i ) (�ni?t > ��i'..1 6001222'
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<br /> 5.Generatdi s Name and Mailing Address 01 2 l 848 E L
<br /> Generator's$110Address(if different than malting address)
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<br /> Generalor'sPhone: 9,16 7.'rr;
<br /> 6 Transporter 1 Company Name U.S.EPA ID Number
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<br /> 7.Transporter 2 Company Name —
<br /> U.S.EPA ID Number—
<br /> ('-[,i'r;-JN .WINP `RG tSJQIL 11'':x"
<br /> 8.Designated Facility Name and SlteAddrass &A # (t7}ii4 U.S.EPA 10 Number
<br /> Faciiily's.Phone: -; e�tt{ 4jh,yri�i. Fl�f
<br /> us, 9b.U.S.DOT Description(Including ProperShipping Name,Hazard Class,ID Number, 10:Containers i1.Total 12.Unit
<br /> HM`' and Packing Group(iFany)) No: Type Quantity 4VINoi• 13•Waste Codes
<br /> 1 i~ rjr,i SRA Hf;? iR,0113 3 1=if # ' `r" 9100M,
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<br /> 14.SpeclalHandling lnsfruclions'andAdditional lNo atfon { r, 'J,�y.r14 rpt C T
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<br /> 15. GENERATOR'310FFEROR'S CERTIFICATIO :I hereby doclare that the contents of this oonsfgnmenl aro fu8y.and accurately described'above by the proper shipptng name,arra eie.ciassifiatl,packaged,
<br /> marked and labelediplacarded,and are.inall ro pects in proper condition for transport according to appl(cabte internaltonatand national governmental regulations;It export shipment and I am the Primary
<br /> Exporter,l cattily That the contents of Oils const time ntconform to the terms of the attached EPAAcknoWledgmantofConsent.
<br /> I,portityflia�the Waste minimization slateme ti entified in 40 CFR 262 27(a)(If t ansa large quantlty$anerafot}01(b)(iii fa a smali:quanp generator)is true"
<br /> oneralors) /ferdrs dntedrrypedNam'
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<br /> 16.nternational Shipments - •� .�
<br /> i— ❑Import to L I.S. ❑Export from U,S, Port of entry/exit:
<br /> ?I Transporter signature(for exports only): Dale leaving U.S.:
<br /> 17.Transporter AcknowledgmeniofReceipt p(MatedaPr,
<br /> Trans rLU
<br /> ' P/rntedrTypedName Signature Month Day :Year
<br /> Transporter 2 PrinledrTyped Name Signaturer
<br /> rY ,. Month Day Year
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<br /> 18.Discrepancy
<br /> 18a.Discrepancy Indication Space El Qua* ❑Type ❑Residue
<br /> ❑Partial Rejection ❑Fuji Rejection
<br /> Manifest Reference Number:
<br /> 18b.Ailernate Facility(or Generator) :U.S:EPA ID Number
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<br /> LL Facility's Phone:
<br /> C3 18c,Signature ofAlternats Facility(or Generator
<br /> �onlh Day Year
<br /> 19.Hazardous Waste Report Management Method Cod 5s(t.p.,codes for hazardous waste treatment,disposal;and to yclitWsystems)
<br /> LU 1 2. .. ,� � 4.
<br /> 20.Designated Facility Owneror Operator:Certification f7eeoipl of hazardous materials covered by the manifest except as noted in Item 18a.
<br /> Ll Pdnted/iypod Name Signature
<br /> Monih Day Yoar
<br /> EPA Form 6700.22(Rev.12 1Z) Previous editions ar obsolete. ----'—t
<br /> �, - ,- .-„ -t• GENERATOR'$INITIAL COPY
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