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Reasr,print or type.[Farm d8WQned forum on elite(12-phch)typewuritar.i Form Apfxoved.OMB No.2750-0039 <br /> tUNIFORM HAZARDOUS j'.GeflGm!xJDN`Jmb0r 2 Page f aF 3 FmegwxyRespmse=onllsstTraeklingNumtw <br /> WASTE MANIFEST J J K <br /> [ S Ger�Erwes Name and f,AaAirig Add-en Gerleratafs SrteAddress IdddfBrent than ma.lin3 address} <br /> Gerl=raw~s Phone: <br /> f TrarsC-rW 1 Compeay F1MM U.S.FPA IIT Nvroer <br /> 7 Tram pUtter 2 Compaiy Name US EPA IC N:xnber <br /> F pts grzed Fadbty Name and S:le Addnw U S EK ID Nmber <br /> Fac+.r,s=h ane <br /> sa 9b US.DDT Uesapbw l ndudig Proper Shipping Name.Hazard Class,IC Nu r:)erC .amens <br /> HM *0 Paddllg G-P Ie any)) � ,1.7o12.Unit <br /> 12.Wave codes <br /> No. Type gvanGtyty WWoI. <br /> 1 <br /> OG <br /> W <br /> !1J <br /> Special Harding InsUlrctior>S a*n r,]j,ti_r.o°7.tOr^atian <br /> G£N�PATORTDFFEROR'S CWTICATION: I hwebydedere that theroxftSlrS Ol 7h:2:onstgnmwl are hily&VaoaraWlydesMed ah3:e !7w propershippng nm .and vadaWed pac..r;ec <br /> r~a it and fabeledptacarded,and are in ad respects i n proper conditon W uamport nec.raurg%appkaNe irRemsbyialarid ndb&W gmrammentol mplallarls.If expert Oapme-a Bard lam the Pnmary <br /> Expcdet.I certlyMkhe contenbi3lN3cwmlFmenl miko,tothr lamisciltie=KZed EPAA6=a 41CgrwdarConsent <br /> I ser fr that tte waste miikrkzatim swernmt idsntllfed in 40 CFR 262.27:a'. I am a large quirt;y genernn or tbl j I am a srra:i quanuty ge-ers' .is m. <br /> Genarwc:7s01eWs PHnredlTyped Norm Sgnah re pay yiAr <br /> a 15.1rv,^;:;:nal Shiprnerrts <br /> Z U fo U.S. ❑Export`rum U.S. Port of 1111(b iluk <br /> Trans::^,r s:g•tiature(tx exports only; Dab D U.S <br /> 17 Trwrspl:lerAi$monledgrrreN a Romp]of MaseriJs <br /> Tnrnparoat'W r;d 7;pe^Name S:gnah" Mum Day Yaar <br /> O <br /> IL <br /> rn <br /> Trarlsiax1v 2 PnrtKWypad N mw $gnakae Month flay Year <br /> 1d Diszreparcy <br /> 10a.Cw-"arrcyr-,di[a4wSpace ❑ Cx>mndly ❑Type ❑Rl6idee Pt.lRejection ❑Fril.Nob. <br /> ',IarresY Re'erence'I,.T;�r <br /> 18b Alter-ate Fad Ary(w Genw orj U.S.EPA 10 Number <br /> ca <br /> � Faoldr's P�:-z <br /> 13C srgie:�'eorAUrna'aFa-i.!r;orGerkalcry <br /> � stn any Year <br /> a <br /> z <br /> r <br /> i 11 <br /> 19.hlazardreu%Nas'a Report Manegemenl MOW Ca4es(,e.r odeafur haxardor s wWo Irearnenl,dfi. a .ind rc:iCrg systems+ <br /> ,� 1 2 7 a <br /> 23 Cesjin,�e I Fadty Ow+m or Operator,Certifi atiw!of receipt V hazardous matenais canned bA arra mandestexcW as nod in Item 180 <br /> Print yped Herr 5 r.,.re V I 1:1 Day Yea r <br /> EPA Form 870)--22lRev.3-05i Prerouseditionsare obsolale. OENERATCR'S INITIAL COPY <br />