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Please print or type.(Farm designed for use on elite(12-pitch)typewriter) Form Approved,OMB No.205NO39 <br /> UNIFORM HAZARDOUS 1,Generator ID Number 2.Page t of 3.Emergency Response Phone 14,Manliest Tracking Number <br /> WASTE MANIFEST CRS/!!1110317 8009136 1 015482413 JJK <br /> 5.GenemWs N ma ar� Mai[yygg Address Generators Site Address(if ddfarent than ink"address) <br /> Cif o f�:G�'f o N <br /> -ISdp NAvy 10/11/c �'i°t'eef <br /> 17t-Glff--'i GA 9SQ06 -f fDC��oN/ CA ?120.3 <br /> Generators Phone: 2 0 q) 913 3.2 73 <br /> 6,Transporter 1 Company Name U.S,EPA 10 Number <br /> 41-frid 6vvir,,-,-Aej141 .S`ervccl G900S38d(, 77 <br /> 7.Transporter 2 Company Name U.S.EPA 10 Nxber <br /> 8.De*natgd Fa'lily Name and SiteAddress U.S.EPA 0 Number <br /> r/-F o�o9Y /.'C. <br /> ,Nwy qs Iohdts Soul of B�ttr <br /> Be7f ttr/ NY 84003 <br /> FaciliYs Phora: 900--239-.39 4t3 00/0000 <br /> 9a. 9b.U.S.DOT Description(vxiudng Proper SNppuV Namp Kazard Class,ID Number, 10.Containers 11.Total 12,Unit 13.Vhste Codes <br /> HM and Packing Group ff anyl) No. Type Quantity lA MI. <br /> rx 1'A16'V-R CR A //.f Zg v 0 UJ WAS So P352 <br /> (De6r,s, mcfo,^ o;11 oNelel fuel j C/n 2 D Y <br /> x 2. <br /> LU <br /> 4. <br /> 14,$pedal Handling�RG#l7/I�(ERG Litructions and ook;^1 Ilel,;cle) Lve6e �//'roPr%nfe 1°PE ev e.�A 4N 00/89 <br /> I5.•GENERATOR'SIDFFEROR'S CVMF1CATION:I herebydedere Prat the eoi of this emsigri nent are 11 and accurately described above by the proper shipping name,and are dassifed,packaged, <br /> marked and labeled1pla2med,and aro In all respells In propercondifion for transport accooding to applicable intemafional and national govemmental regulations.If export shipment and I am Oe Primary <br /> E)wter,I cergly that ih.a contents of this consignment conform to the tants of the attached EPAAdurwAedgment of Consent. <br /> I certify that the waste minimizaton statement Identified in 40 CFR 26217(8)(if I am a largo quantty generator)or(b)(Al am a small quantity gereralor)Is Lus. <br /> enerato'elOPerors PrintedJtyped Name igaabup_ Month Day Year <br /> _-r 15.IM.amaWd Shipments <br /> ❑Import to US. ❑Export from US. Pat o0,entrylextt <br /> t Transporter signature(for exports only): Data leaving U.S.: <br /> CX 17.Transporter AdrmuledgmentcfReceiptofMaterials <br /> 0w[ T2nspater1 PnnledRyped Name Sig natu eM1 Month Day Year <br /> IL tc"-� <br /> Q Transporter 2 Pnnted7Typed Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue G Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Atlemala Facility(or Generate U.S.EPA!D Number <br /> U <br /> rdi FaaTity's Phone: <br /> W 1Be.Signature ol'AltemateFacility(or Generator) MorLh Day Year <br /> a <br /> z <br /> N 19. ous W Report Management MOW Codes(l.e.,codes for hazardous waste treatmem,dsposal,and recycling systems) <br /> 0 1. 2 3. 4. <br /> ",Vq[ <br /> 20.De naiad Faci ity,Owner or 0 rator,Certifition of receipt of hazardous materials covered by the manifest except d in ir 18a <br /> Pnndffy N Sgna'y <br /> 9"11 ayt e�(` <br /> EPA Form B7 22(Rev.3-05) I'MviobYMtknsareobsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />