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Please print or type.(Form des ned for use an elite(12-P4ch)typewriter.) 0 0 6 1 3 6 3 2 1 6 K ffi <br /> if NlFf]RM HAF ARDDUSForm1.(ienarator ID Number 2.Page 1 of 3.Emergency .iiij=sa P%M 4. an%st Tracking Nu mpruved,p1419 No.�Z/050.17439 <br /> Naand <br /> Gal <br /> MANIFEST006136821 <br /> 0 61 3 6 8 2 11 S r1� <br /> Genarabrs me and Ma it g Address GaneraLv's Sita Arltlosss(Rcrftent than malting address) <br /> Gerera0or's PtIBnB: . <br /> fi.Tragepdter t Company Flame <br /> U.S.I=PA ID Number <br /> 7.Trsnsperter2 Compan11 y Name <br /> U.5.EPAtp bumter <br /> 8.Uesigrz d Fatafsy Name aril Site Addsa s 4q.3a ;Ub <br /> U.S.EPA ll <br /> FaWtys Phone: <br /> ga 4b.U.S.DOT besuom Rwj&g Prier Shippkng Name,Hazard Class,ID Nlanbsr, <br /> HM and pal r.-P(d any)) 70.Con4tktBrs 11.Total 12.isng <br /> t No. Type Quantity yyt . 13,Waste Cedes <br /> � <br /> z 2. <br /> w i <br /> - -_- <br /> 4 <br /> 4, 1WHandiirrglmttticdonsandAadigonallnfamalon <br /> b—� 1 <br /> 15- GEI tfRAiDA`6lnFF@t3CR's CEttTIFfCAZ10H;I hereLy tledare not Fhe eontenteaf des mnsigamantae ams <br /> atakad and labeted/plararded,and are in ail respects in Ui soc-*Wy de--bed above by the proper ahWirlc ,err!are class Bed,pacltagea. <br /> Prov uxrdibm for rral rroC*hg lo appii wa intemm"and natkm1 govemmerllal cu <br /> of uh reAulaeorss,R OW sh rrrsM end t am ftPrisrrary <br /> &Portet.I certify 11A the cartenls .tar*nment dam w ft terms of Ute atlaoned EPAAtkwmtedgmera of Consent <br /> I oertifp @rat the waste mhtimiz l 9464 ra ider tW in 40 CFR 262.27(a}(it l am a large gwnrity 9&ftw tor)or{b) 1 am a smaN <br /> Generavajoifilli maw quantity�aratnr)s5 hire. <br /> ^ Signal � ear <br /> f« .- aZY <br /> -r o.Iniamationas pmerds <br /> 1 ❑Import to U.&- ❑Expert from U.S. Pori o€en3ryrexft __ <br /> ? 7rarrsaotf5rsignefwe(fat exporrsanlyj. <br /> Dale leaving US.: - - <br /> 14�= t7,Yrartiaiaortarp�ugrdgnsan>o}ioiA4aferlats <br /> T%111s Or 1 pr-Me Name Sgnature <br /> G flat11 y <br /> aUy <br /> 4 reit 2 nledr�YDed Nanta Signature k �_g f]a Yew <br /> ~ 4A)l , G� <br /> t8.Discrepanry <br /> 18a.Clscrepanci tnd'"WD Space Quan3 ry ❑Type Rsdue <br /> ❑4Reec=fio.n ❑Fut R. on <br /> 18b.All"te Facility(ar Generator) fdanitpst Retarent 2 Nlnnbar. <br /> Ui EPA IQ Number <br /> C� <br /> LL Fecl it�Pho <br /> p ne: <br /> W 18c Signature ofAltamalo Fal for Generator) <br /> q tlandt bay Year <br /> W13.hazard—Waste Report ManaPrne"t Mts2W Codas ti,a.,codes for ttazardautt waste raalmeM,&spnsal:and recyctny systerosj <br /> a. <br /> D86191'M F361ty Oestarar Gperator Cert:{se V"of reoalptof hazardous rna[%Bis covered by the rnardf�si axcopt as Hated in Item 48a <br /> Tvpr�Nalae _ Si otdlt fSay ear <br /> EPR Farm 8700.2 { V. ) rs edidansare to. DESIG A ED FACILITY TO DESTINATION STATE(IF:REQUIRED) <br />