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Please print or.40. <br /> UNIFORMHAZAR]EE$ t Gerator ID Numb <br /> Folin APA P•DMB Na.2050-0039 <br /> 2.Page 1 of 3.Emergerc <br /> Response Phone 4.M Tragi n Number <br /> WASTE MANIFM �:�t�;0)(M r��: ��.������ JJ K <br /> 5. <br /> Generator's Hama and Mailing Add a. Generalots Site Address Xdifferent than mailing address) <br /> .�, �1,.Ti��F�z'rl� � ifs ? <br /> TYG'+f'.]LTA. ..l=i-f s' <br /> '_ •i�,r�axr�. i';i ;frk� �1� "iR'a�,a1.x�r3. <br /> a� vAp rA f�rXVW ki <br /> Gen rafods Phone: � -47+21iv <br /> 6.Transporter 1 Company Nance w U.S,EPA ID Number <br /> ,'n�!�rSr' Fr i-i:s-+:�r r inr n: �+� e+r�+a..}ger• - L. <br /> 7:Trarapbrfer 2 Ctrrnpany Name + U.S.EPA ID Number <br /> • _stip... <br /> S.Deslgnatsd Fadtiiy Name and Site Address U.S.EPA 10 Number <br /> #J�Jkxa��I <br /> a.: 4y7T114[l[l,t:P1 rl: 2i3!� � �+ <br /> Farallty's Phone.- <br /> 9a, <br /> hone:9a. 9b,U.S.DOT Desori0on{including Proper Shipping Name,Hazard Class,ID Number, 10 Cbrdalners 11.Total 12.Unit <br /> HM and Packing Group(d any)) No. Type Quantity yyt fyU• 13•W�asta Codes <br /> 1. <br /> 1 F t:a <br /> C7 <br /> 8.. <br /> 4. <br /> " ti .Special Handl.Ing Indructions and Addigdnal Information <br /> 15, GEN ERATOR'SIDFFEROWS CERTIFICATION:I hereby declare that the contents of this consignment are putty and aeouretaly described above by the proper stripping name,and are classified,packaged, <br /> marked and labsledlplacarded;and are in atl respects In pmwommon for transport s 000rd rig to apphcahle international and national gevemmental regulafions-9 exportshiprnent and f am the Primary <br /> Exporter,I csr*.that the coolants of this consignment conform to the terms of the attached EPAAcknowladgment of Cement. <br /> I certify that the waste minimMon statement identified In 4e CFR 262.27(a)(H i am a large quantify generator)or(b)(ff tem a small quantity generatoo is true. <br /> Generator'sloffemes Pdatedfiyped Name Signature <br /> g r r Month Day Year <br /> J 16.International Shipments <br /> f ❑Import to U-S- ❑F_xport iron U.S. Pohl rlhylexit <br /> Transporter signature(for exports only): Rateleaving U.S.: <br /> De 17.Transporter Acknowledgment of Receipt of Materials <br /> O Transporter 1 Printedfryped.Name Signature , <br /> MmO Day Year <br /> Transporter 2 Pnn9 FTypad NameNit <br /> z <br /> Signature + Month Day Year <br /> 16.Discrepancy <br /> 18a,Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial R pMon ❑Full Refection <br /> Manifest Reference Number: <br /> 18b.Wtemate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> Fadlity's Picone: <br /> 180-Sbnsture of Alt®male Facility(or Generator) Month flay Year <br /> 4 <br /> PH-,ard ste Report Management Method Codes[.e.,oodes for hazardous waste treatment,disposal,and recycling systems) <br /> 4. <br /> ility Owner or tor.Cenitirallon of receipt of hazardous materials covered by the inWes:except as noted in Item 1Beey J J : Signature �} 10011thDWy <br /> EPA Form 8700-22{Rev.12-17] Previous edifions ars obsWgle. <br /> TRANSPORTER COPY <br />