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P!easa Orin cr tvae. 'Farrn des .areed frur i:sAm plit- I o-nilml t—,it— I <br />W -A r-orm cirtx-,ez lKev. j-vaji vrevious quitions are otisoiate. DtStGIWATE�D FACIC177TO GENERATOR STATE (IFAEQIJIF�ED) <br />UNIFORM HAZARDOUS <br />1. Gen alar 10 Number <br />I <br />2. �aqa of <br />3. Ernerjen�y Rosporse Phone -FT-M-anifest <br />Iracki;i—Ember <br />WASTE MANIFEST <br />I CAD92- ii6>F3107 <br />.14- *31-599- 1 <br />0034535,0193 JJK <br />5. Generator's Name anto NWilavAddress Gansiratces Site Address (if different than mailing accIress) <br />S iD -1 S 710 <br />CHAI Z TER, w to in <br />Generator's Pi4e! <br />6. Transporter I Company Name U.S. EPA Number <br />3— N"P, C'0 <br />2 Company I'laine, U.S. EPA ID Nutubar <br />S. DasAvated Facility, Name and Sue Address U.S. EPA ID Nuftar <br />C-* 51d -3v 41 <br />-3-7:777-�r- %5i? lsig— gra-1--s <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, 10 Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (it any)) <br />Quantity <br />iffluvol. <br />13. Waste Codes <br />NO. <br />Type <br />LU <br />2. <br />4. <br />14.Special Handling instructions and AddifionallntGrmaWn <br />15. GENERATORISJOFFEROWS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the snipping name, and are classified, packaged, <br />*proper <br />marked and labeled/placarded, and are In ail respects in proper condition for Lrarispor. according to aQ p:lcable internatioral and national governatertal regulations, 1' export shipment and I am the Prirnary <br />, <br />Expor.ar,,t centy that the contents of this mrsignment conform to the terms of the attached EPAAckrkedgmani of Consent. <br />I cerfify that tha.vaste rrunimizadmi statement idertifled in 40 CW62.27(a) (if I ama!argo quq1fitYrerara1e4.1LL4;dl am a small quantity qanerator)is tree. <br />Gen66 Nror's?n dITyped signaure klcnth Day Year <br />16. fiternatlonag Shipments Xpc; <br />n1port to U.S. E from U S. Pod afentry"04 <br />Transporter signature (for exports only): Date leafing U.S.: <br />W L <br />17. Transcorter.Acknowtodgmont of Receiptof MaterielsU <br />R <br />0 <br />Transporter I Prints Name Signature Mwtq Cay Year <br />a. <br />Z <br />Tanspdrer 2 Pr-inted/Typed Narre Signature Mwih Day Yaar <br />ti <br />DiscrLoancy, <br />Ilia. :Yscrepancy iraicaticii SpaceQuan6tr ❑Type RSS.dLilk ❑Partial R*cJ. I R,*.tcri <br />Mw,:Iest Rsfew.,s Nurpbsr. <br />18.,. Allerrats Facility (or Generator) U.S. EPA 0 Number <br />LL <br />Facgity*s Phone: <br />IW <br />18c. Signature dAtarn.ate Facility (or Generator) <br />6forIn C3/ (aer <br />S2 <br />U11 <br />1.3. nispiesal, and recrc0gsyslenn3) <br />LU <br />1 4-4 <br />3. <br />20. Designated FacAity0wnerorOpmmr.Cor4,,imtiw.ofrerppt ofna7ardousmateralsoveredby the manifestexcept asnalsornItem 18a <br />Name1 <br />Sgran re IF 11 03t, �ar <br />L�Q' <br />W -A r-orm cirtx-,ez lKev. j-vaji vrevious quitions are otisoiate. DtStGIWATE�D FACIC177TO GENERATOR STATE (IFAEQIJIF�ED) <br />