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u --'I <br />Please print or type. (Form designed for use on elite (12 -pitch) typewdmr) <br />roan Npprovee. VMe No. 21NiFUU39 <br />1. Generator lU Number Page gency Response Phone MaManfeet Tracking Number <br />UNIFORM HAZARNOUS / 2. t d 3. r�r <br />WASTE MANIFEST C L,UDiI Ibvq "70 <br />C'I <br />' ,.� .'7 00"]06 1. / V 1— L., <br />5. Ge We Name and Maiiin Ad ress Cetmmta's bile Address (a Oriented then malting addmae)V <br />GeMustt SPfro <br />raTurer Company area U.S. EPA ID Number <br />. Trenspoder 2 Compalry Nama <br />.b. PA ID Number <br />8. Des lgpaled Fe Iny amen, Ile Address U.S. EPA ID Number <br />Y 10 <br />P <br />93. 96. U.S. DOT Description Onic udtng Proper Shipping Name, Hazard Class, ID Number, te. Consumers 11. Total 12, Unit <br />HM and Packi Group Of any)) No. Type Quantity WUVoi, 13. Waste Codes <br />o 144 r of t t 5, �2 �M1�, SdAiuw� <br />1 4 b br <br />2 <br />w <br />3. <br />4. <br />4, Spedai Harderg lnskudlons andAddlionai n(amabon <br />75. GENERATOR'b10FFER0R'b CERTIFICATION: (hereby laconic that the mnlenis of this mnslgni l are fully and accuratelydeseribed above by the properehippag name, and ata classified, teenaged, <br />marked and labeledlaboerded, and are In all respects jr, proper rendition for transport according to applicable International and nmlvnal if <br />governmenlel reformists, export shipment and I am the Primary <br />Exporter, I caN'dy Had the collars of Ors Designated conform to Vie terms of the affected! EPAAcknowbad menl of Consent <br />hcenfi/ that the waste minimization statement ldanlKetl N 40 CFR 262,27(a) (it l am a largequanfly generator) or Old (If l am a small quantify grana or is true. <br />ane a aaYe Pnn o ypetl Name - gna WB on ay ear <br />.J t,lniemaliamal Shipments <br />❑Import to Ub. ❑Expod from U.S. Porfoienhy/exit: <br />Transpodersi nature for ex onl Dafe leavl U.B.: <br />� t7.TmnspadarAciurowletgmenlolRecelpl of Matedals <br />o Tr r i Pdn pad Name gna u on ay r <br />TranSpoder2PdnledRyped)Na� t lure <br />0 oath ay ear <br />W. <br />r— <br />I Dieaopancy <br />18a. Discrepancy lndicatron Spars Quan ly ❑Type ❑Reswua ❑Parbo Refection ❑Full <br />Rejecgon <br />Manifest Reference Numb6r <br />18b.Ntemale Facility (or Generator) U.S. EpA ID Number <br />7 <br />U <br />R <br />a <br />FadGl's Phone; <br />w <br />a <br />180. Signature ofAllemale Facility(a Generator) Month 2y Year <br />z <br />N19, <br />Hazardous Waste Rated Management Method Codes fee, rates for hazardous waste treatment, disposal, and recieft systems) <br />w <br />4, <br />20. Deslynaletl Paolily 0rrner or tlperalor. Cadi6mAuon of raceipl of hazardous malariels covered by the m;afesl excepl as noted in item me <br />Printed rryp ad Name BignaWte M1lonlh Day Year <br />