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.,._ R .11 <br /> PF58N'eFSrR <br /> rintortype. Form Approved. OMB No. 2050-0039 <br /> OM HAZARDOl7S1 . Generator ID Number _ . 2. Page1 of 3 Eme ency Rg ponse4. Manif tracking Number <br /> 137 •WATE MANIFEST �� 103 687 <br /> SKS <br /> G [ Name and M iii g Add ss y G n rotor's Slte Adtlr (if different than mailing address) <br /> aTf f �; Y t arU " .. ., Yam- g7 <br /> LGenerl,a <br /> t Phone " '"' " ` ' " ut :leuLl 'X ¢pant P,me 'U.S, E�k IP; Number <br /> " V P AyE7,4' si[Aar a, , <br /> 7. Transporter 2 CompanyN {t�`-' - U.S. EPA ID Number <br /> r _s <br /> ' <br /> C-D <br /> ice. '--^-*�. sw`9x U.:+7 r" ., t i ''_ r . A <br /> S. Designated Faclty Name and Site Address r W y ; nq , a I . — <br /> j rop a„ 4 [ j ; a E. ,:_,rY d flU.S. EPA ID Number <br /> v 1P u <br /> A"u°U4a>w y'� a <br /> Fecilltys Phone: <br /> go 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers - 11 . Total 12. Unit _ <br /> HM and Packing Group (if any)) - 13. Waste Codes <br /> No. Type Quantity WLNoI. -' <br /> 1 1;i ,��... . � r p o 1 5<r k p.1 fti; ir+ j. ...°.' . <br /> o .. :i: l � , a .z ei: . t ,' yl u iEr criLl { el1`il ` ,e : <br /> z 2. <br /> ur <br /> 3. <br /> 4. <br /> 14 Special Handling Instructions and Addltlonal Inform h v, SI ( ,, '.?B — <br /> UyS --�. <br /> 6 ' vt ° f dr§fit e'U Y " 31 'a.N 7y rp Id `T ¢ s iL ; a u " o3 fy'3 1a; 1 � L. <br /> b - <br /> . .pti r ,;, o" ?odahe. r a. Au' nor r5 ' xrsr t m e -arnad ' = d^ <br /> 15. GENERATOR'SIOFFERORS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged <br /> marked and labeled/placarded, and are in all respects improper condition for transport according to applicable International and national governmental regulations. Ifexport shipment and I am the Primary <br /> Exporter,'I codify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> certify that the waste minimization statement identified in 40 CFR 262.27(a) (if am a large quantity generator) or (b) (ifI am a small quantity generator) is true. <br /> Generators/Offerors Printed/Typed Name Signature Month Day Year <br /> 16. International Sh pments [-1 import U.S. - - r ❑ it/ ^„ L <br /> 6- . po Export from U.S. Pod of enti <br /> - <br /> Transporter:signature (for exports only) ; , - Date leaving U.S,: <br /> of 17. Transporter Acknowledgment of Receipt of Materials r <br /> CC TraP�potter 7 PrintedlTyped Nprpe. . Sign�tura.5 r - Month Day , Year <br /> - t r <br /> t,�L <br /> z .Transporter <br /> sm � ,.,. fd � <br /> Tran porter 2 Printed/TypedN me signeture yf r eawa <br /> r <br /> J <br /> 18. Discrepancy <br /> Ins. Discrepancy Indication Space ❑ quantity El Type ❑ Residue ❑ Parfial Rejection ❑ Full Rejection <br /> ManifescRefo•ence Number: --- - - <br /> �. - 18b. Alternate Facility (or Generator) - U.S. EPA ID Number <br /> Facility's Phone: .. <br /> 18c. Signature of Alternate Faclliy (or Generator) Month Day Year <br /> Q <br /> i ' <br /> 19. Hazardous Waste Report Management Method Codes (i.e, codes for hazardous waste treatment, disposal and recycling systems) <br /> 2. 4. <br /> 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the Manifest except as noted in Item 1 Be <br /> Pnrtted7yped Name �, v , SignatureM nth Da Year <br /> r ^ f t i <br /> .. V G`! *,t'y.�l : M1 /-a r r f t t Y <br /> i u �Y? ” 1 <br /> EPA Form &70022kReG1217) Prewouseditionsare obsolete. r DESIGNATED FAC TY TO GENERATOR <br />