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9eas0 print of type, (Fora designed for use un elite ( 12-Pi(C11) lyprvtriter) Form Approved. OMB No. 2050.0039 <br /> 1 Genoator ID NumWf 2. Page ! of Emeroen } Respon ,e Pi one d. fila Nest T eking Numger <br /> `UNIFQRM HAZARDOUS f r <br /> WASTE MANIFEST 4 , _; > FL <br /> 6. Generators ante and Maiing Address Gonorn!oes Site Address (if different than mailing address) _ <br /> GeneralotaPhone <br /> 6: tansponer .Company t1 <br /> oma — -• -- -� ,S. EPAlOfiumiwr <br /> . . . . <br /> _ . <br /> 7. Transponer 2 Company Name U.S. EPA ID NumUlf <br /> 8 DeSlt;naled FaC ( ly Man a afxi Site AJdress U.S. EPA ID Numbar — — w- <br /> p�ysp�j �r'�rta I <br /> Faa tis Phoria: 4W a _ <br /> ga. Ob. U.S. DOT Description (including Prober Shipping Name, Hazard Class, 10 Number, 10. Coulamers t !. Total t2, Unit TQ. Vlasta Codes <br /> .HF,! and PadupgGroup (if any)) ac No, Type Quantity Wlivol, <br /> Mi <br /> 2. <br /> 3, I <br /> 4. <br /> 14:Spacial Hatidling fngrutSons and Additional Informatiob <br /> I AG Wi6 SAAm } , <br /> 15. GENERATOWSMOEROR'S"CERTIFICATION: I hereby declaro that the contemsof th1s oonsigrment oro fully and accurately described above by the proper shipping natio, and a(e dassifie¢; packaged, <br /> marked and labs opiacatded, and ate In nil tespocts in proper condition for transport according to applicable Imemallonal and national governmental regulations. If export stipment and i am tho Primary <br /> Exporter, I cei!i1y %at the conlenls of this consignment conform to the terms of the attached EPA Acknoviledgmeat of Consent. <br /> I ear0ty that thevlasle mkdmlzawn 44ntoment identified In 40 CFR 262.27(a) (if I am a largo gaanlity generator) or (b) (it I am a small an iy generator) is we, <br /> I rteroM not ype Name ryno ure ! ay ear <br /> tj <br /> f8. tofernatfonal SbVroents <br /> z ❑ import to U.S. ❑ Export lrom U-S. Porr1 of entrylexil: <br /> -- <br /> Transporter $1 nature jfot eX s onl : Dote leaving U.S,: <br /> ' � 17. TransporterArknou",t;dgmont at Necefpl of tdaleri�s 1 <br /> fans " dot 1 Pnn dyfyped a gna y � I / Month ay year . <br /> ej <br /> Transporter PdAlpdfTypdName Signature Month ay ear <br /> a <br /> 18. Discrepancy <br /> I8a: Discreparq Ind1ca6on Space Quantity 0 Two ❑ Residue ❑ Partial Re tort <br /> jec El Full Rejection <br /> Manifest Reference Number. <br /> 18b. Ailemole Facility (or Generator) U.S. EPA ID Number <br /> V <br /> LL Pathic ' P <br /> IF orGanarala) Month Day Year <br /> N11% Hazardous Waste . 0004 Management Method Codes (ka., codas for hazardous waste treatment, disposal, and (ecyding systems) <br /> 2. g. 4, <br /> 20, Designated Facility Nn rrr or Operator: C nation of recelpt of hazardous materials covered by the ry)an fest except as noted in Item 18a _ <br /> pkeffypodNamo f f i / Sk�9attrra w 4 ' / Month Day Year <br /> EPA Fon 8700.22 (Rev, 3.05) Previous editions aro obsolete, __ _ DESIGNATED FACILITY TO GENERATOR <br />