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M ClJ -UOp <br /> 2 0 <br /> N <br /> 7 -0 v <br /> 0 <br /> CD <br /> HAZARDOUS ' atnr IpNom, ' (D <br /> 0 O <br /> rtµeN1FE57 0 (9 (D <br /> Q g,rs Now and mai6.g Arltlress �Pam t yr 3 (n 'tr �$ <br /> mab6 eae ram M nen <br /> 13 20560 F e 3 w <br /> 5 Pa— <br /> ,a:sna"�'1 C-Vany Nan- 130 CJE CD <br /> N <br /> -r-ar to CO m Name u CD <br /> CD <br /> Fa-ty++a<a srte Add ess u- n <br /> 2 <br /> (D <br /> FPA lo,,-4w `G <br /> Faasuys Phone. <br /> gb <br /> ga. and P C:uig 6rouP lrf amj11ndud�ng Proper-Pplrrg Na.-Hazy d Class.Ip Numb?r (D <br /> Hit <br /> or , ib C.Qnf3mpry „TMg 12 Urn M <br /> aN° Type W»ra.y wl!ft 3*..at -, n <br /> v <br /> W O <br /> W � <br /> D <br /> 14.Special Handlrng Ir15 WCtinnS and Additional Information <br /> 15. G rted an OR'SlOI I EROR'S CERTIFICATION:!hereby declare that the contents of this consignment are lolly and accurately described above by pre proper shlpp,r.9,yam ad are ���, <br /> marked and la6eredll boa rded.conte and are rn af,on respects.proper condition for f the <br /> according to appticabie intemational and national governmental regulapors.It export shgrnert,aro <br /> Exporter I rzrh'fy prat the coolants of this Consignment conform to me leans of the aftWhed EPA Acknowledgmen'.:f C unsent. <br /> 1 certify that the waste minimaaGon statement identifed in 49 CFR 262,27(a0(if I am a large quantity generator,r t,,-it]am a small uan <br /> GeneratorsOffero(s Printerllryped Name r' g tltY generator)is inia <br /> Sigffature <br /> mum Oaq Yw <br /> 16.lntemational Shrpmenls <br /> 2 ❑Import to U.S. ❑Export from U.S. Part of entryleOq <br /> Transporter signature(tor exports only): <br /> 77.Trans {late leaving U.S.: <br /> � porterAckr,ovAedgnrentofReceip[ofMaterials <br /> Transporter 1 Printed,'Typed Name <br /> p Signature <br /> d '.kr.>h Da, veal <br /> QTransporter 2 Prirried?yped flame <br /> r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑Duanfty ❑Type ❑Residue ❑Pamal Re,ecwn a FA Rem-- - <br /> 18b,ARemate Facility(or Generator) Manifest Reference NumGer <br /> U.S.EPA ID NumL r <br /> V <br /> tu- Fardlity's Phone: <br /> 16C,Signature OfNfemate Facility(or Generator) <br /> _ Meny^ Da} Yd <br /> 19.Hazardous Waste Report Management Method Codes(i e.,Codes for hazardous waste Ireatment,disposal.and recycling systems( <br /> 1. 2 <br /> 3. <br /> (7 � <br /> C � <br /> 2D-Des grated Faality(hu ter 0r Operator Cen f1§011 of receipt of hazardous materials covered by the manifest except as rented in Item 18a n <br /> Prinfed/Typed Name D Q <br /> Sgnalure y� <br /> � I _ <br /> 2 � <br /> =orfn 8700-22{Rev 12.17} Previous editions are obsolete <br /> GENERATOR'S INITIAL C N <br /> � O <br /> CY' v w <br /> rnCD <br /> co <br /> - m w <br />