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Please print or type,(Form designed for use on elite PIV typewriter.)
<br /> 221 er,-.i,7 Form Approved,OMB No,2050 0039
<br /> UNIFORM HAZARDOUS I I-Generator ID Numbs Page I of 4,Manifest Tracking Number
<br /> IS!
<br /> WASTE MANIFEST TX
<br /> S. arierefor's ameend MaillrigAddress 100 4 8, V3 0 4 SKS-
<br /> Gfinoratoeli Site Address(if different than mailing address)
<br /> 741'1i"; I
<br /> 5,
<br /> Generator's Phone: 91
<br /> came
<br /> " U.S.EPA
<br /> r., lD Number
<br /> 7.Transporter 2 Company Narno I If S.EPA 11)Number
<br /> "ll.E10asignated Facility Name and Site Address
<br /> THIN() FLITIDs lic, U.S.EPA ID Number
<br /> 'Tl
<br /> 0 1 W 1111"IF 'mmiki f. r
<br /> a.,
<br /> Facill 's,Phone:
<br /> ga, 9b.U.&DOT Description(Including PropieriShip Ing Name,Hazard Class,ID Number, 10,Containers 11 Total 12,Unit
<br /> HM and Packing Group(if any))
<br /> 13.Waste Codes
<br /> Type Quantity WL/Vol,
<br /> 1,i,iowilcr-41
<br /> P A I I L I D
<br /> O ±J„(}R
<br /> 2,
<br /> UJI
<br /> (D
<br /> 3.
<br /> 4.
<br /> 14,Special Handling InstrUM11-1 7,i5A-d-,rMql Info 31111 K
<br /> T�SD 4 TPA "N"CA
<br /> iw4 41-4-00 4 1 0
<br /> L jg, N'VPI-9'P,91
<br /> "rill 14S in 117'riA .-1 r,r, jam)r RV
<br /> 15,. GENEPATOR'S/OFFEROR'SCERTIFICATIONe Ih reby declare that the contents orthis consignment are fully and accurately described above by the proper sliipping.namri,and are vlassilled,packaged,
<br /> marked and latided/placarded,*and are In all rapped proper condition for transport according to applicable International and national g9vimmental regulations.If export shipment and I am the Primary!,Exporter,I certify that the conlenis of IhIs oolmilgrime conform to the terms of the attached EFAAcknowledgment of Consent;
<br /> I coffify that the waste minimization statement Ident[Od In 40 CFR 262,27(a)(Iff am a large quantilygeneratof)or(b)Off OM a small:quantity generator)Is true.
<br /> 1570tor'slOfferor's PrintedfTyped Name
<br /> Signature
<br /> Month Day Year
<br /> -j 6.International Shipments
<br /> ❑Import to U.S. D Export from U,S, Port of6rilrylexit:
<br /> Transporter signature(for exports only): Date leaving U.&:
<br /> 17 Transporter AcknovileddrhahtbfRecefplolMaledels—
<br /> LLI
<br /> t2 Transpo�tet%1 Ptinled/Typed Name I 819miture
<br /> Month Day Year
<br /> 0
<br /> CL
<br /> Z TranWORVnK Oacame-
<br /> Signature
<br /> Month Day Year
<br /> 18,Discrepancy,
<br /> 18a,Discrepancy Indication Space Type [JResidue ❑Partial RJectloi
<br /> IT E]FIf Riljeclf�,
<br /> Manifest Reference Number;
<br /> 18b,Afternale Facility(or Generator) --7—
<br /> UA EPA ID Number
<br /> w Facil(b/i PhoQo-
<br /> '10&Qhalure ofAftemate Facility(or(3aneralor) I j Month Day Year
<br /> 19.Hazardous Waste Report Management Method Codes ',a,,codes for hazardous waste treatment,disposal,and recycling systems)
<br /> D 2 i
<br /> L20.Designated Facility Owner or Operator:Certificatiop of i acelpt of hazardous materials covered by the manifest except as noted In Item 180
<br /> PrInted(Typed Name Signature Month Day War
<br /> EPA Form-87,90-?2 Previous editions ark ob!olete.
<br /> rti
<br /> GENERATOR'S INITIAL OPY
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