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e print or type. (Form designed for use on eltte (12 -pitch) <br />UNIFORM HAZARDOUS I. Generator NUNUmbef <br />WASTE MANIFEST 1 C.k,II 1) k$7vt3•; <br />Yti�Ggtl,zsra 4c -:fir^ a�5-:F3#�i �`'�-owfkz.�ef��:>w"3iH)itt;2S <br />7. Transporter 2 Company Name <br />�!i'�alaY�rrapax,rtr+e�astr.` �tva;a�waa <br />8, Daslpna(e¢ facl(Vy Namevand Sile Address <br />r i:z rear <br />i�rg;;glr,, sH� 'i�srai.�ru�3rn.3'-y <br />C:s�y� 8,�f815LiCr;a <br />Facility's Phone: Ea.A7-23R-aFk13 <br />ga. gb. U.S. DOT Description (induding Proper Shipping Name, Hazard Class, ID Number, <br />HM and Packing GroUp(if any)) <br />Gicr FCfr�t kUsHaa iA4--zIIxrs7 x 3i, Bs3aar6aa'r <br />iST?1'..II pnoe - <br />76 Spot Address d <br />f€�-;Y stet. t•n �;e;,�1g. <br />Form Approved. OMR No. 2050-003 <br />.PA ID Nomber <br />PA ID Number <br />t , <br />10. Conlalnem 11. Total 12. Unit <br />No. Type Quantity WIW I. 13. Waste Codes <br />41 <br />%!JG taG <br />�. <br />RWFF <br />R'SIOFPEROR'S CERTIFICATION: I hereby declare Thal Ne coolants labeled/placarded, end am in all respects in propercontlillon for VanspoeNty Thal the contents or this consignment conform to the lentis of Ute atthe waste minimizallon statement idenlifietl In 40 CFR 262.27(a) (if I am ls PdntetllTyped.Neme's7'.-C /LjcLPV �G fi 1;... I bi'za•,a..wfA+ /�f�(�«cg.��.k.t-' . Month <br />l_l import to U.S. U <br />Transporter slgnalure(for exports only) <br />17. TmnsfederAcknowledgmenl of Receipt of Materials <br />rienspoder I Printed/Typed Nem <br />I <br />.p 18. Discrepancy - - —_ 18a Discrepancy lndiplion Space <br />❑ Quanllry <br />Operator. Garlificalion of receipt of.hazs ous materials <br />evlous eddions are obsolote. <br />Export horn U.S. Par(ofentry/axil: <br />Dale leavino U.S. <br />end <br />❑Residue <br />as tided in Item IBa <br />Month DaV Year,. .,. <br />❑Padlal Rejection ❑Full Rejection <br />ISE- I(�6VF-�i E'.YY t'7iGII.F1 Y 7f } g•f:kVf�F1,+11c7Ct <br />