|
Pleas��pnnt.or type. (Form designed for use on is[&e 12 pitch) typewriter.) . - - - Form Approved. OMB No. 2050-0039
<br /> 1. Gen rotor ID Numlaer 2 Page,1 of 3 m ResR i Php 4 Manifest Tracking Number
<br /> UNIFORM HAZARDOUS $tf ;, , 1 > 6 ) ` l
<br /> cc
<br /> WASTE MANIFEST h 0
<br /> SKS
<br /> r, !. 15. Generators Name and Malllg Address Generators Site Address dlfferen(than mailing address) -
<br /> i" Si ah ral_ Cs dO Tri
<br /> a
<br /> Generators Phone: �k "" �' A
<br /> 6. Tra iS Mac:? rF m ". i �d 1 k 7 ad - U.S. EPA ID Number
<br /> 7. Transporteri2 Company Name - U.S. EPAID Number
<br /> 8. Designated Facility Neale and Site Address t — 4 p U.S. EPA ID Number
<br /> `, ., ., ,("a tr#ai('z" Pr' sv,' t:3f .43,1 � .'..r~ _ Y
<br /> al IT
<br /> 71 as�tt . .M. 1 s
<br /> Facility's Phone:
<br /> go. 96. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 . Total 12. Unit - 13. Waste Codes
<br /> HM and Packing Group (if any))- No, quantity Wt.Nol.
<br /> i 1 Piz �'syl 1!4hrr`s Ll E nkf8 i vs ,. ; , y
<br /> 0
<br /> ?Rk
<br /> " d7 m S 'x e '`
<br /> yCyb s, I ijr
<br /> �
<br /> CE ? Lu 6 t
<br /> ,3
<br /> If r. "4 Special Handling nstructoni Additional Information
<br /> IMPS
<br /> 32 ERS017 a � .A
<br /> , l s a a es . Ct r Baa zL4 jeV k -hSi
<br /> n ws :. j13 kaIir 0a , 1Ac r . Ni, add g uaawr „ ; rtt w ar,�chjj . 01'is � � ISn % ":� r #, gi .al . A,�� � Pu, "a
<br /> Nfa t11rn= a
<br /> .,..; 15. GEN CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper skipping name, re classified, packaged, _ P
<br /> marked and labeleddalacarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and l am the Primary
<br /> Exporter, I cerify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent.
<br /> I certify that the waste minimization statement identified in 40 CER 262.27(a) (if I am a large quantity generator) or (b) (if I.am a small quantity generator) is true.
<br /> Goal {l(f rs Pn }ted{tTyped N me - - Simartu� �ark) .,q x�{ Mont Day YeaY , jr
<br /> y `:) �� ii :grate
<br /> —r IS. I : tenatioonal Shipments1:1 § ❑ Exportfrom U.S Port of enirylexit:
<br /> i— -Impart to U.S:
<br /> z Transporter signature (for exports only); . Date leaving U.S: -
<br /> w 17. TranspoderAcknowlpt edgmentof Rt of Materials _
<br /> FE Transporter 1 Printedl-typed Name Signature r VIA, Day Year
<br /> O `€ A} a nra"p ^ u � C ✓u.1` frje°vi'ry' w �u
<br /> Q Transporter 2 Printeid dName -ter Signature f es+ " Me ttp aDay Year
<br /> hi ?to
<br /> 10. Discrepancy t Pae_"'I"'r
<br /> ma. Discrepancy Indication Space ❑ quanti ❑ Type ❑ Residue- T -
<br /> ty ❑ Partial Rejection ❑ Full Refection
<br /> Manifest Reference Number:
<br /> F 186. Alternate Faulty (or Generator) - U.S. EPA ID Number
<br /> Facility's Phone: .
<br /> w 18c. Signature of Alternate Facility (or Generator) MonthDay Year
<br /> Z
<br /> ,
<br /> .1,9. HaroardousYlase Report Management Method Codes ( e , codes for hazardous waste treatment, disposal, and recycling systems)
<br /> 3. - 4.
<br /> 20. Des[griated Fac 6ty ner or Operator: Codification of becadiatof haiardous materials covered by the manifest except as noted in Item 18 ,
<br /> Print dlTyped Nam ey,� �' r
<br /> C' Signatureea
<br /> Month o�y '"
<br /> r'f sf f v°..r'"y ')e / r er Cr'` E”" ` f '', ul ✓ F,
<br /> EPA Pop 8M' 22 ,(Rg% 345), Q,reyfous edltto s eo s DESIGNATED FACILITY TO GENERATOR
<br /> 21. . : ) ft - _ ' ,a=xsv+ .^ ` �'n=rn" kv'
<br />
|