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Please print or type.(Form designed for use on elite( 2-pitch)'lypewrlie'r,) `? vWT2 Form Approved.QNIB No,2050.0039 <br /> UNIFORM HAZARp0U51.Generator ID Number 2.Priia'e t of 3,Emergency Response Phone 4, nifost�rT�rackin�N��bo�3� SKS <br /> WASTE MANIFEST i ktikirj d rc1.tr.'�tGr } .,,),z 1 �r�r. t4tat} `.(7lak�! gf�}}JJ h"rr�S <br /> 5.Generator's Name and Mailing Address Grm6ralor's Site Address(if different than mailing address) <br /> l2i 1,fI" i , �tlfr :t1,!. RECEIVEO MAR j 4 2016 <br /> tr .r.I <br /> Generator's Phone, <br /> 6.Transporter I Company Name _ U,S.EPA ID Number <br /> 1)l;"F TY--RLE-94 'Z Y8 f t I" 3l <br /> 7.Transporter 2 Company Name U.S.EPA Number <br /> I <br /> 6.Designated Facility Name and Site Address U.S.EPA ID Number <br /> MEAN MRBM19 "I'Al( J13981 I JI, <br /> ttt•)�"'t;�����✓s7::�I � �f"if�<,�����`4�t.'i i 4'� <br /> Facility's Phone; <br /> ga 9b.U.S.OOT Dasedpiion(including Proper i hlpping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit i3.Waste Codes <br /> HM and Pecking Group(if any)) No,. Type Quantity Wt.Nai. <br /> x € t <br /> Mr-fl 131.RA 14A,141 it s WNSY')'} 80"c-tos'r DIN FP <br /> cltt»BRI Ue PEETiR,l..)�.2.�'I�) ` / fi 11;r f z t�(Lz) t ; t i�. u� ._.. <br /> Z 2, <br /> CO _ <br /> 3. <br /> s; <br /> 1A.8pecial Handling Instructions and Additional lnformatlo I S.'O,-9J 8877S484 C 13 w,9 3" <br /> 24 HR EVER'r)t�'NCY 41"806 j ti-17h, (A1 1 Ck' 4 t } , r ,J ( {✓. <br /> C 1' f is 11 1 �' - S '9rr twi f.'*" 1' A t CUCI fi 40'r r In+:. :mV <br /> 15, GENERATOR'S10FFEROR'S CERTIFICATION! I h abyAWare that tha contents of lhs consignmanCare tujly.and accurately described ahovaby ha propershipping name,arxf are alassffiad;packaged, <br /> marked and labeled/placarded,and are in all respect In condition for transport according to applicable inlemallonal and national governmental regulations.lf export shipment and I am the Primary i <br /> Exporter,I certify that the contents of this consigmar tcoptorm to the terms of the attached EPAAcknowledgment of Consent <br /> I certify that the waste minimization statement fdontilli d in 40 CFR 262.27(a)(if I am a largo quantity goneralor).or(b)(if i:am a slnall quagtitgganerator)Vie. <br /> r' <br /> '96 n8 Viitffytor's Fnted(rybed Na�nre Srrdpgtuie Month Day Yoar <br /> N .�r....�.` <br /> a 16.Internatlonal Spr pmenls ❑Export Bpm U.S Po n(en tezik <br /> i— ❑Impart to U S, p by <br /> Transporter signature(for expo s only): Oa a leaving tl:S.: <br /> UW 17,TransporterAcknowiedgmentofReceiptofMatedal$ <br /> OTranspo - Prihted[Typed Name Signature, Month Day Year <br /> Transporter 2 Pnnte y ed'N Signature o ii y-,- 'Yea04 <br /> j = I <br /> .18.Discrepancy <br /> l8a.Discrepancy Indication Space Quamity ❑Type El Residue J � j rj <br /> Partial Rejection Ful{Ra ectio <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V ! <br /> Facility's Phone: 1 <br /> w !Signature ofAilernata Facility(or Generator) Month Day Year <br /> d ' <br /> Z <br /> ig.Hazardous Waste Report Management.Method"Co4es(i a,,codes.forhazardous waste treatment,disposal,°and recycling systems) <br /> d: <br /> 20,Dosignatled Facility Owner r Operator:Cedillcaliorj of receipt of hazardous maleriats covered by the manifest except'as nood In.Item IBe r <br /> Printed/Typed.Name Signature.t /' Month Day Year <br /> f .)...i%i. ��t^rr,;T./' %`�f, f y!� � (�✓�.f u� .7 '.rl .�+-- <br /> EPA Farm 8700,22(Rev,3-05) Previous etlitirinS areiob et ; "" 0 rS1MOkD FACILITY TO GENERgT R <br />