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F r typewriter.) � Form Approved.OMB No_2050-0039 <br /> Please pent or type.(Form designed.or use on elite(12 pitch) <br /> UNIFORM HAZARDOUS e (L�Ip_Numbe,z} �.Pege 1 of _3r E+nergpn�),R�e posse Plans d-Rtanifest Tracking Number p p <br /> WASTE MANIFEST )Ll 011392829 FLE <br /> 5.Generator's Name and Mailing Address Generators Site Address(r{different than mailirr�address' _ <br /> __._ .. ,-.`-�' - .r r. rw:; Lv.'•.,it !`_rl ra <br /> - _ ,_r_ 4.`;`)t.r ;.)�^.._ :�r•it-�!. �F, f: !-y - .�� i-. .i. r}! .:_ �.. .'3 -!-:, i:rttt;°`r'11� FiVr <br /> Iti!i; t:rt •"'�_�i'1!% <br /> Generator s Phcre: <br /> 6 .ransperter Company r ame U.S.EPA ID Number <br /> 'r'iC'fCl i7'-'lc!tt l�=i Fillt-t 3.;i, ifir=: mi1'1It, <br /> 41�1ift°j[ [ <br /> 7_Trdnspodw 2 Company Name U.S-EPA!D Number <br /> t-(;iii!ti'✓ii :)z';-,. <br /> 8.Designated Facility Name and Site Address;tt fr,cf ''( U S.EPA IC Number <br /> Facility's Phone.' -i461f;;69 4 )>•J!tfrr?7=i`r`f r; <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID P:amber, 10.Containers Tota: 12.Unit <br /> 13.`Nasse Codes <br /> HM and Packing Group(it 3ny'i) No Type aLalttity YlLivel. <br /> 11az r'r_l•.^.ri'--. <br /> tr <br /> Z 2. <br /> W <br /> 3. <br /> 4. <br /> t <br /> 74- Handling Instructions and Additional information ;-- .i�%`-i--'t'i i'.. . _.is� ;i i.!:_ t': �+! `s�r .'t i i q i <br /> Lj <br /> 53��t�3 <br /> 13. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described AbGve by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in al:respects in proper condition for transport according to applicable international and natkmal governmental regulations.If export shipment and I am fne Primary <br /> Exporter,I certify that the contents of this consignment conform m"'terms of the attached EPAAckreviedgment of Consent. <br /> I certify that ere waste minimization statement Identified in 40 CFR 262.27(a)[if I am a large quantity generator)or(b)!if I am a small uantity generator',is!me. <br /> Generator's-Me-roes not yped me ..gni rg„{��. r rt f t- 1:+'!a i t. t !I?[ ;pr; ay ear <br /> -j 116.International Shipments <br /> r=— i <br /> L i mport to U.S. _J Expo,^,from J.S Pon of entryfexit <br /> 2 Trans order s'nature for exports ori•': Data leaving U <br /> rx 17.Transporter Acknowledgment bl Receipt of Materials <br /> C. <br /> Transporter 1 Printedlfyped NameMonth Day Year <br /> O '� '?. [!:?-Eta.ori :<1=R :.:.i ( "' _.! f/1'a i�4:)'L <br /> a , ”; <br /> rn <br /> Transporter 2 Printedr7yped Name Signature Month Uay Year <br /> .- <br /> IB.Discrepancy <br /> 18a.Discrepancy indication Space ��--(( I <br /> J Ouaniity T.❑.rp- ❑Residue Penial Reiecticn J Full Rejection <br /> Manifest Reference Numoer <br /> 18b.Alternate Fac4ty(or Generator) U S-EPA ID,Number <br /> J <br /> V <br /> Q <br /> u- Facill's Phone: <br /> LU <br /> W 18c.Signature ofAlterrateFackty(crGenerator) Mzr!h Day 'fear <br /> !Q <br /> Z <br /> .9.Hazadous Waste Report M@nagement Aet-.od Ccdes(i.e.,codes for hazardous.waste treatment,disposal,and recydiag systems' <br /> LU ;L� 2 3 4 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materiais covered by d;a marir t ex ept as noted In[tern 18a <br /> Pinta .y Name (S' turn Month Oay Year <br /> ` , l \ 0 1 ' i <br /> EPA Eorm 87100-22(Rev 3-05) Previous editions are obsolete. � 0� iGt•Ill rD t'1CI1_f t Y 0 DESTIi ATION S INI'lE(IF REQUIRED) <br />