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ID0'f15655S8K6 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Page 1 of 3. RNs P 4 Maniksl Traekin Number <br /> uNIFORE HAZARDOUS GF'f1s7113t? <br /> WASTE MANIFEST 0 0 71 8558 SKS <br /> 5,Generators Name and Mailing Address Generator's Site Address fit different than mailing address) <br /> Generators Phone: <br /> 6.Tr�wtarterl.ompanwNanoa -YSTDIR INS. U.S.EPA ID Number 7- �1QI�YQtyt�ili-'_�c <br /> 7.Transporter!2 Com�rpann,,yl�:Natamee U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address 3AFE7'—,'--KLEFN (}f' i- 1 0R1t A U.S.EPA ID Number <br /> E,8A :MITI? AVF. <br /> NFk1ARU <br /> +0-795-4400 aTM9B0BE7418 <br /> Fadli s Phone: <br /> ga 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, W.Containere 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group if any)) No Tye Quantity WINol. <br /> 1" NUN RCRA HAZARDOUS WASTE,LIQUID TT _ 1. <br /> p FTHYLENF KYCOL. 5OLUTIQN {LESS THAN 50%) <br /> d'a <br /> Z Z. <br /> U) <br /> C7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:EVG T R'411717 3S>?.: <br /> c'4H EMERSENCY#800-4EB-1760-UHfSKfTFI-Contract retainedby generator confers aency authority <br /> n <br /> an initial transporter to add or substitute additiaal trnsaartery on nenera?or's behalf. <br /> 15. GENERATOR'SIGFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the cornetts of this consignment conform to the terms of the attached EPA Acknovdedgmenl of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)('d I am a large quantity generator)or(b(#I am a small quantity generator)is true. <br /> GeneratorslOfferor's PdntedlTyped Name Signature Month Day Year <br /> ')1 ? <br /> 16.international Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Pod of enlrylexik <br /> = Transporter signature(for exports only): Date leaving U.S.: <br /> K 17.Transporter edgment of Rpt of Mate6ais <br /> Tran a P/tin yped Na Sig Month Day Year <br /> a G <br /> gnsporler2 d/TypedName Signa re Month Day Year <br /> K <br /> r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Quanhty ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.A@emale Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> L Facility's Phone: <br /> LOU 18c.Signature ofAhemate Facility(o€Generator) Month Day Year <br /> a <br /> z <br /> S2 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UA t 2 g, 4. <br /> 20.Designal FaciltylOwner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pdnis ad Name Si tune Monti fm Day Year <br /> EPA Fo )0 7t2,�(RR�P� -17)Previous editions are obsolete. DESIGNATED FACILITX TO EPA's e-MANIFEST SYSTEM <br />