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Please print or type. Form Approved.DMB No,2D5O039 <br /> UfF1Ft]Rhtl HAZARDOUS I Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4 1520116 <br /> bst Tracking Num�er- <br /> WASTE MMIFEST 1..�`�[? ) J -3EJ r 600-42443�c JJ K <br /> S.Generator's Name and Matiing Ad*nq a ,rival pftZa f.WV� dtam; Gerfera&s Sits Address.(If d'dlerant than mailing address) <br /> IJ Wjh LcoaS kE>CIq' ?Rr,Rrtfh art. <br /> 11t 3r rP. f fi'.le3y ti I athtrrx3 PA ±f 33,—:a #MA <br /> Generator's Phone: 46r>je-4•21r,,. . <br /> 6.Transporter 1 Company NameS.U. EPA ID Number <br /> T?t1�r "'t�',a."c�t Fs}* r•.�k s�Y:t�3n MOO003,1211 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Fatuity Name and Site Address U.&EPA VD Number <br /> UlGMenno k8rdtat i �.,y <br /> 20W7Y��d..t_ <br /> FacIlit's Phone: <br /> ga. 9b.LS.DOT Description(irduding Proper Shipping Name,Hazard Class,lfl Number, 10.Containers 11.Total . 12,Unit <br /> HM and Packing Group(if any}) Nn Type Ruantriy " MjVot 13,Waste Codes <br /> rY' 11:001 F:'�4 <br /> PC?If ERG#I^I p k30-1 .14 <br /> 2, <br /> 4, <br /> 4;S�i Nand npp <br /> f �Inshur Ts andAdditionalinfglmation <br /> f <br /> S3YC g .'-- -•_ 1 s3f 3AF ]�Tt 1rr1!fd! .SSC rµsi,nr <br /> 15. GENFRATOR'SlOFFEROR'S CERTIFICATION:t hereby declare that the contents of this consignmmt are fully and accurately described above by the propershipping name,and are classified.packaged <br /> marked and labeled!placarded,and are in all.refects in proper condition for transport according.to.appiicableAnternatoaland naVonal governmental regulations.If export shipment and i am the Primary <br /> Exporter,l certify that the contents of this oregnment conform to the:tarms of the attached EPA Aclu-cwtedgment of ConsenC- -. <br /> I certify that the waste r imimvation statement identified in 40-CFR-262.27(aa(If l aim a krrge.quanthy generator)or(b)(itI am a smallquantlty generator)is he, <br /> erl s[Qflerors P" yped Narile Sign - ._ Mo Day Year <br /> 16,[aternafloAdil Shlpmerds <br /> f ❑I mport to U:S. ❑Bort from U.S. Port of entrylexit: <br /> Transporter signature{far exportsonly}: Date ieaving U <br /> IX one <br /> 17.TransprAcknowtedgment of Receptof Materials <br /> LLA A <br /> Transporter 1 Printed+Typed N 1 Signature I Month Day Year <br /> 4 ransPa r 2 PrintadFfYped:Name. Signature + Month Day Year <br /> 19,Discrepancy <br /> 18a.Discrepanoy Iridloation Space Quay 0 Type El Rosidue 0 Partial Rajedion ❑Full Rejection <br /> Manifest Reference Nombar, <br /> 1eb.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> Factiily's Phones <br /> 16c.Signature of A#emate Fadlly(or Generator) Month tray Year <br /> a <br /> z <br /> I 9.Haztardotus Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,dj%03a 4 and recycling systems) <br /> r' 2. 3. 4. <br /> 1. <br /> 20.Designated FadlIty Omer or Operator.CertiNcalion of receipt of hazardous materials oDyared by the manifest exoppt ajnoted in Item 1Ba <br /> Prir}t�dlTyped iVam "*, # Signalurs• <br /> Day <br /> VY <br /> EPA Form 87222 Rev-12-17) Previous adltions are obsolete: " T tN$POTRi C6PY <br />