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<br /> Form Approved.OMB No.2050-0039
<br /> Please print or type.(Form designed for use on elite(12 Pitch)typewriter) 2.Paof 3Eonse P one, 4.Manifest Tracking Number
<br /> ma�3ge0fcy Resp �A4 p053:29963 SKS
<br /> 1.Generator ID Number r r r;
<br /> UNIFORM HAZARDOUS I;C;:F.1..r�7?-w�I•---r
<br /> WASTE MANIFEST Generators Site Address(N different tlran mailing address)
<br /> ,5,Generators Name and Wailing Address
<br /> RAEr�yr�:P Corp c
<br /> t'AACZ '
<br /> Geneators Phone. .` •" U.S.EPA ID 1tr.,', +, . .
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<br /> 20,5
<br /> d�f�CorppaNam
<br /> S T �I {—Yvtrit S"a SYSTEMS, It'll-
<br /> U.S.EPAI Number
<br /> ZTransporter 2 company Name�_ CJOry
<br /> 8.Des "LEAN Facility Name and Site Address .. Ear g E�ARE10ftS fti 30Nl -r
<br /> U.S.EPA ID Number
<br /> 567g NORTH A °TNr pI,�F;ti� T
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<br /> nft��Stl.11 T r y ,a
<br /> FaPhone: 10.Containers ll Total 12.Unci
<br /> 13.Waste Codes
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<br /> ge 9b.U.S.DOT Description(including Proper Shippin_g Name,Hazard Class,ID Number, No Type Quantity- W1Nal.
<br /> HM and Packing Group If any)) +�W
<br /> DOM
<br /> 100 7 D00
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<br /> }: 1 NA3082y HAZARDOU9 WASTE, LIGUID
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<br /> - 14 Special Handling IeshU -sand Unfglmahon rr r,ria r ?7" QI, SJR 3's S.c'35.
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<br /> TSD AG z -
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<br /> $$,, ��,,..,� pp T1'
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<br /> ^EE ATTAChiMENT
<br /> 15 GENERATOR&OFFEROR3CERTIFlCATR)N. thereby declare that the contents of Urs consignment are fully and tonal
<br /> and national
<br /> Pmper s&Ifexpname,area red I arntd;Packaged•
<br /> marked and labeledlPlacarded,and are in all aspects m proper condition for transport according 10 applicable international and national ggvemmental regulations.If export shipment end 1 am the Primary
<br /> Exporter,I cenly that the contents of this oonsi9nmenl conform N me teens of the attached EPAAcknowieegment of Go
<br /> lame small qua hty enerat )is hue
<br /> I certify that the waste mmimiza6on statement idenfifad in 40 CFR 28227(a)(if I am a large quantity genealor)a (' D, ,,,,,,r
<br /> atpeal0(ferors Prin yped Na S a Month
<br /> 7
<br /> International Shipments ❑Exportfrom U.S. ,' Port of )exit:
<br /> F ❑Import to U S. Date leaving U.S.:
<br /> Transporter signature(for exports only):
<br /> w 17 Transporter Acknowledgment of RecelDtof Materials MY
<br /> � p y, ear
<br /> T r1Pdrdedyf Jjame SignaWa re Ijp lJ
<br /> w/ � a
<br /> Z Tanspo d !typed Name Sign a
<br /> Momh Day Year.
<br /> 18a.Discrepancy Indication Space ❑ puaniily ❑Type ❑Residue aural Rejection Full Rejection
<br /> t Manifest Reference Number.
<br /> U.S.EPA ID Number
<br /> 18b.Alternate Facility(or Generator) -
<br /> J
<br /> L)
<br /> LL Facilitys Phone: Month Day Year ,
<br /> w 18c.Signature of Alternate Facility(or Generator) -
<br /> 4
<br /> Z
<br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recycling systems) 4
<br /> OLl0 2
<br /> 3
<br /> 20.Designated Facility Owner or Operator.certification of aceipt of haZardoUe materials covered by the manifest except as noted in Item 18a Mr,nm. Day Year
<br /> Printed(r Name - Si aloe )yl
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<br /> �-P{evious edl ons areobsolete
<br /> 7,0-2.(Ree �5 . DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)
<br /> EPAFoci@
<br /> r, r ,at:r'w
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