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v,/r( / ritllllilf INII�NINQ!lOIIlI�1111 <br /> Please print or type. 0 0 6 4 5 3 4 4 4 S K S <br /> Form Approved.OMB No.2050-0039 <br /> t.Generator lD Number 2 Pa e l of 1 m R s P Manifest Track umber <br /> UNIFORM HAZARDOUS •'I Jtt1�►•+�'��'1�"`� � 9 � �-�°�' ''��° ,i;� 100F;q- -43444 SKS <br /> WASTE MANIFEST <br /> 5.Generators Name and Mail,ng Address Generators Site Address(if different than mailingaddress) <br /> IIIPT°'A - tin-Zt.fP;. Gr! F. ��r=t, - f r,1.�• ;r `_f.3T <br /> I S�:?t�'!: r,j.. ! 1;k ;-t:Sr`f1 Pfa i='t.� ;, :i••.>j1t:a '• 1�i'`1"rr�r; , 1/�,�<�� `;t:��:rf 'r'i'. P� <br /> TPA! •a rA `�!!".. ".>:.r L.� .�,,; �h,_ <br /> 'ir_'1 ..3?it7-13.-7 ; <br /> Gonerator's Phone: <br /> ti,Tr � prr n J �7VSTFMS T NF. U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> 8.Designated Facility Name and Site Address ct�Fffrhh 7 v j.t j= `� 11F7 !-`0j_I Fn pp<7-1-1 U.S.EPA ID Number <br /> Facial es Phone: <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID NumbK 10.containers 11.Total 12.Unit <br /> HM and Packing Group('d any)) No. Type Quantity yyWd, 13.Waste Codes <br /> 1. N.I)N--DCPA HA-7APn,0U9 WAP-777 t ?�j�I^ 00( T' <br /> p <br /> w 2 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional information TID,FVG Ar' 19A r'.:,G <br /> ='4H EMEABFNCY#800--468-1760—CH/9F.'T!7T-.rontrar7t • atatr•�- dy -Xgi'lCJ <br /> or! initial trans orter to add or 5U6stltute additienai trancporter�s on eneratrirI s behaaf. <br /> 15, GENERATOR'SlOFFEROR'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 labeledVacarded,and are M all respects in proper condition for transport according to applicable international and national governmental regulations.H export shipment and I am the Primary <br /> Ex;wrter,i certify that the contents of this consignment conform to the terms of the attached EPA Adma wledgment oft. <br /> I ceitify that the waste minimization statement ideniffied in 40 CFR 26227(a)(H I am a large quantity generator)or(b Lam a small quantity generator)is true. <br /> Generator a PrintadRyped Na Signature Month Da Year <br /> r e ( r.J, 1 I o <br /> F 16.International S is <br /> Import to U.S. Export from U.S. Port of entrylexit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Adwwiedgment of Receipt of Materials <br /> N <br /> Twqyter 1 P ypy�pRSig re Month Day Year <br /> l U 01 J3 Za <br /> Z r <br /> 'hdrisporteQ~TypeSame Signature Month Day Year <br /> t= <br /> 1$.Discrepancy <br /> 18a.Discrepancy indication Space Ej Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> C7 <br /> ti, Facility,Phone: <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> � 1. � 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in item 18a <br /> Printed/Typed Name ignature nth Day Year <br /> EPA Form 8, 00,22(fjgv,12-1�) Previous editio s are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />