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i Please print or type.( orm designed for use on elite(12-pitch)typewriter.) F';;7: �{+ ��c ;i n: e'3 2-19.2 Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MAN FEST ti ; C :� E 3 Ll i s y'�t .°yw - `c 0 Q'7956 F LE 5.Generator's Nan a and Mailing Address Generator's Site Address(d different than mailing address) _!ar::2 •tv�v Generator's Phone ;:^ - T A n`: -B`--'1 .;i-.0s P n.r 6.Transporter 1 Company Name^ U.S.EPA ID Number �.S3r,`4a" r5 i= rr ^'a-. �J?tciC?5 il: MA D 0 3 6 3 2 2 2 $ v 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Fee 14 Name and Site Address U.S.EPA ID Number Peir+� ss3Road _ FacisPfione:' ga 9b.U.S.COT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total qWt.Nol. 13.Waste Codes HM 1.and Packi g Group(9 any)) No. Type Quantity D,30 1 343 a1-4r rl,'�kgi:._T AE 0KO -3.�.1.i�I�'NE U-N FT.L•'��.i/'NT11 1� rry � C7LIn-rom4J 0 1 D f 0 t1 r J Uj W 2uiy1'ecJ•TE;:LAt4'MAB.--E-k'-"U?DS,id��.`J.�'i �r?-� �r�'.•�f'��L. __'1� -43 .X AUC CL DEt'dAT tP,ELl,3,F%rt G r 1 D i= r L 01 1 6 F 3'jN31 ;:SAS c j-AtDiZI G L'QUID,N. S.,(HYDROG EN DQt]1 135 _ r ER "?(i iEy,a.1:FG Ii G Q 1 D a= s t3 9 C F 1"RQ.L N3256,"o-NAS,E s::OFZRet SIVE BASIC,1qORGAN1C-, D002 135 d.J. ., SODIUM H FOCHLORiTE,SODIUM H`rDROXIDE),l's G Ii G 1 1 D 0 C 1 5 14.Special Handl ng Instructions and Additional Information 1. :CCS LP IX30 r- ? .' CRC 1XSDP 2. CGR 1,'SDP 4. LCGR6 1X3108 WO#5-j1 22•, r L EET#442106 LPOTARGET-021' 15. GENERAT R'SIOFFEROR'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, marked and labeledlplacarded,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 Exporter,I c rlify that the contents of this consignment conform to the terns of the attached EPAAcknowledgment of Consent. I certify that ie waste minimization statement identified in 40 CFR 262.27(a)('d I am a large quantity generator) (b)(if I am a small quantity generator)is true. Generatof s Printed/Typed erne Igoe on ay .ear UL-?- : y fiG 2 1 15 JOB -j 116.International hipments F_ ElImport to U.S. Export from U.S. Port of entry/exit z Transporter sign ture for exports only): Date leaving U.S.: W 17.TransporterA knowledgment of Receipt of Materials � Transporter 1 Pri yped Name Signature on Day Year a Sean Spitzer I QTransporter 2 Pri ted/Typed Name Signature Month Day ear OC t- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quant ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Fa ility(or Generator) U.S.EPA ID Number J_ V IL Facilitys Phone: LOU 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z U519.Hazardous ste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 2. T . 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Print WyNeme Signalu Month Day Ye EPA Form 700-22 Rev.3-05) Previous editions are obso a e. DESIGNATED FACILITY DESTINATION STATE(IF REQUIRED) iear arbors has the appropriate Derrnits for and wiii accept the dvaste t�1e a3eneratDr�a 5 iDDfnC1