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",. ase pa or type,(Form designed for use On ellta(12-pitch)We*r,lei,) Form Approved,OMS No,2050•DO39 <br /> UNIFORM HAEARDQUs I Ge.erator ID Number 2 Page 1 of 3.Emergency Response Phme 4 lfsst 7 r9 Num <br /> WASTE MANIFEST 0 J I K <br /> -5—re' me e'eralrrs NaandAng YL Address Gerbrafor's Sde Address(it diRenent aw malng a6drest) d I� <br /> GeTr.I<,5,nc•ar��s Phone. <br /> 5 a m e U S.EPA ID Number <br /> Transp 4w2 Cwpany Name V8,EPA la Number <br /> S 7esogn w Fad51y Name and 5ileAddrmss LIS,EPA ID NLrdw <br /> Faaht.s Phone: <br /> ga. ya U-S.DOT Desugiort(ndudrng Proper Stripping Name,Hesand Gass,IA 4ffljb r, c-' , 11 Total Unll <br /> Hr 1 and Packing Group(If sry)] 13 Waste Godes <br /> Mi- T•c� �:�-�.1� VJiJUpI. <br /> O <br /> r <br /> w <br /> M 2 <br /> Lu <br /> 0 <br /> 14 SWR�3•idt ng!nstrtrdbons vdAddit+onal lydomati m <br /> 044 I.t".r <br /> r .,r� r', r)p!frrrl#.lflrr:., <br /> ,:. GENErATOR'S'OFFERWSCERTIFrGATlON:Ihaabyd=darethaltheccir=n ❑tthi3cc s:.�mpnalQiul'lyandacna!elydescr�edahevellyCfepraperahippiagnaate,err ala .aa::`.ec,pa:ia:=_ <br /> maga and W*edlptaarded,and era in al reaped In ytpp owdl on for treresw0 accmd'n <br /> Expader.I CN*that the cWVmvts o11hs cmiskjonerA conform b the temis of the attaches EPA AckrwAO wH f Con st--t national gwemmenla!rag WauD IB.tf exportshipment end f artt e1B Pr nen <br /> rlpN'}lggtlnll of Carfse.t <br /> 1 rtrify bel flewom ff"ffmzabm 3b&ment kWUfied n 40 CM 252.2?;a (d f am E large 5�w'H pnewj cr(bl(d 1 am a umnd quanhly gent a'.-- istrue. <br /> Genera:ces olferoes Pnnwd7ypej rwrt Signature ':'rr Year <br /> 1E Int=Tat:nalShiprrnrrls <br /> Fi ❑Import to U.S. Euwn from U.S. Port of enrry" _ <br /> K Tragspune'sgrai,:,(for expum only. <br /> I'aH fearrrg U.S.: <br /> W 17.Trarspoite Aclrarled raft of RumV of Maferish <br /> Transporter'Pr NKYTypedr.xme Signature tic-ith Dap Yaaar <br /> ii <br /> rn <br /> C Transporter 2 Printed Typed Name Ye <br /> a <br /> 10.1715u�aan: <br /> lea.p scE,a rr[y ildirxt Spxa ❑171mnGy ❑779e ❑fiaeidue ❑Partial Rejacllpn ❑FuA Rejeefon <br /> Mandest Reference Number. <br /> t8n.AI'errale�a::il.ty¢�r Genera;ori U.5 EPA Ip NumLer <br /> Lt <br /> k F"Iy s Phpre <br /> LLj 19:S+gnatu.*aafARemafe Fau'ityicrGeneralar MEr.th pay <br /> Q <br /> Z <br /> 14.Ha:ard,,.'.Va5te Repan Wnage3*0t Maumd CAdm 4i e,codes icr hazardous wme tw'nent,d_posal.and regding syslerrm) <br /> � 1 2 :1 14. <br /> 20.Den,, Facirty Dvrrleror Operator Cer4C abm of neeelplof hamrdo cs matubk covered ty In=•,.,•.' :1 except as rdwil Wn 1ff <br /> Pr1rnadT,_:7 Name ,t._re bion^ <br /> P <br /> EPA Fame f 790,22(Rev.3-05) Previous editions are obsolete. <br />