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06/07/2008 13:08 2094685672 CLEAN HARBORS PAGE 01/03 <br /> Please pnnt or tYPO.(Form designed for use on elite t2•pitch)typewriter,) Form Approved,OMS No,2050-0039 <br /> UNIFORM HAZARDOUS 1 Cin rator I.Number zags t of 3.Emergency n Pho11 ria 8, anifW Tracidng Numher <br /> WASTE MANIFEST c !„fl/01021 y � f �_. 4���,� 000894563 <br /> F'L� <br /> I. nerator s Name an Waddress <br /> Ma'ng <br /> orator s Site Address(4 nt m ng address} i <br /> - a �;�-. <br /> 01,10 W <br /> enefelW'a PltGrra; <br /> ransparter any atria EPA iD Number <br /> f7 Transporter 2 Company Name — U.S.EPA ID Number <br /> 11 A <br /> 8. eslgnetedaGIi1r"1 al�lte�d ss 0 r}� '* U.&EPA ID Number I <br /> ENV1RONMEN-1 HEALTH <br /> PERPAIT/sFRV10Eg <br /> ga 9b.U.S.DOT Description(indtik Proper Shipping Name,H=rd Class,IG Number, 10,Container; <br /> HM and Pawng Group(it ary)) _ I 13. <br /> Woo codes <br /> X 61-e dAls 10 <br /> w 100 <br /> 40 3181 ZVew(rlo <br /> a <br /> s <br /> 14.��P6aiet Handl Instructions and Additional information <br /> J r'#.2'Yc7 6/? /'-*J 5);� <br /> J-1 4 C'OR- � )a'4�ph <br /> 15. OENERATOR'SIOFFEROR'S CERTIFICATION; I hereby declare that the contents of this consignment are fully and accurately described above by the propershippirto name,and are etessified,pa kgod, <br /> marked and labeled/placarded,and are In all respects in proper oondifian for transport accoding to applicable intematbnal and national governmental regulations,If export shipment and I am the Primary <br /> Exporter,i cerllfy that the contents of this oonsVMent oonform to the terms of the attached EPAAcknowiedgment of Consent. <br /> I cerUly Ihat the waste minimization statement identified in 40 CFR 262.27(a)(if 1 am a large quantity generator)or(b)(f 1 am a S=H quantky generator)is true <br /> Genmtae;Wgror's Pn ed ame nnaftlre on usy Year <br /> ezy <br /> -4 16.International Shipments nn <br /> 1,x.3 Import to U s, LJ Export from U.S. Port of entrylsxil:..._... . <br /> Transporter signalum for ex only): Data I"uimh U.S <br /> 17.Transporter AcyAom"ent of Receipt of MaWriets <br /> rartsporter 1 PnntedlfypName ignature <br /> a <br /> F;iter 2 Axted:TypeO Name5"liure won Day Year <br /> � t <br /> 18.Discrepancy <br /> 1 ea.Discrepancy tndicadon Space Q rantiy 0 Type Residue ❑Pantie!Reliection ❑FWI Rs)ecdon <br /> Manifest Reference N bar: <br /> 18b.Alternate Facility for Generator) U.S.EPA ID Number <br /> v <br /> GFacillr'a Phone: <br /> W 15g,Signature of Alternate Facility(or Generator) Month Day Yeaj <br /> Q <br /> z <br /> 19.f1sttlrdGUs wawa Report <br /> /Management Method Codes(i.e.,modesfor hazardous waste treatment disposal,and recycling systems) - <br /> o s a. <br /> 20,Designated FaOlky Owner or Operator.Certltkation of receipt of hazardous materials covered by the manifest except as noted in nem 18a <br /> Pnn�Name Ignatur® —_-...�. flay Ye <br /> 11 .1 % f <br /> EPA Form 8700-22(Rev.3-05) Previous edhioas are obsolete. �DESIGNA�TeDFA��O _,, 71ON STATE(lig REQUIRED) <br />