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FnrmAnnroved.GMS No. 2050.0039 <br />`IC01 <br />u P"il; u' ;yUO.tr Ullli Utalyllov Ivr scop N, orrw �,� ,v.—r+ •r <br />1. Ge�erata ID Number <br />UNIFORM HAZARDOUSJJK <br />2. Page 1 of <br />3. Emargenuy Response Phone <br />_ <br />- - <br />14. Manifest Tracking Number <br />a r a -^r �• •3 <br />WASTE MANIFEST <br />''>*y.'' <br />001 <br />5. Ge-eretni s Name and Maiiiag Adcress Generators Site Address (if different than mailing address) <br />Genera:olsPt•ate:' '..�z,_�•.,.r. _._,. .._... _.. •1::�--;��KS <br />6--ansponar 1 Company Name U.S. EPA ID Number <br />Tmasporar 2 Company Name U.S. EPA ID Number <br />d. 0eaignated Fauiity Name anti She Address , .i :r 1, : i y v :.%� ' f-,,. ,j r,, ,i;. ..✓ U.S. EPA IO Number <br />- _ ° : " >• ^tire - r` r .r 1:iY/ . :^ f'}r'. i r�Y <`y7� �r. h� ' ✓yy-:.• `1 „4 •-T r <br />_ ... +��g.�„ <br />Facility s Pfana_„ . _ _ _ s ^�•. ,••r"T'� • "'r'y' a.d a '7,a % `�' R .,ice <br />ga_ <br />gb. U.S. DOT Description (in_luding Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />.1. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Pipe <br />Htt <br />and Packing Group (if any)) <br />Quantity <br />W1Nol. <br />2 <br />� <br />W <br />c7 <br />7. <br />4. <br />14. Special Handdng :nshucfiam and Additional Information <br />15. GENERATOR'WOFFEROR'9 CERTIFICATION: I hereby declare drat the contents of this consignment are fully and aauratdy descsioed above by the proper shipping name, and are classified packaged, <br />labe,edlplacarced, and areall respects in proper condition for transport according to appncabs international aril national govemmental regulations. If axport shipment and I am the Primary <br />narked and .n <br />Exporer, I certify that the oDnIants of this censignmerd conform to the terms of die adached FPAAckwWedgmeat of CcnsmL <br />I cartify that the waste m;nirrizatidn statement der,11W in 40 CFR 262.27(a) (it I am a !age quantity generator) or (b) (if I am a small quantity generalor) Is true. <br />C:°narator /CiferorsPrintedrrypcdName Sksakre Month Day Year <br />—j <br />'l6. Interrarionai SNpntents 1 iron U.S. Pon of urarylexit -- <br />LJ Import to U.S. L Expo <br />f <br />? <br />Transp•,rter Signa ure (for 3xports only): Data leaving U.S.: <br />tr <br />L <br />17. TranspoeorAcknowsdgrentofRace,ptofMalerials <br />%lonih Day Year <br />� <br />7rausporter 1 PdritedrTyped Name S�:alure <br />C) <br />Trar4port3r 2 Prrntedrryaed Nacos Signature Month Day Year <br />a' <br />F <br />18. Dlscrepanuy <br />lea. D saepar,cy Indication Space Ll Quantity Type Res;dua ❑ ParLal Raectwn Full Ra;ecbon <br />Manifest Reference ;waiter. <br />} <br />r— <br />I& Aitemate Facdtty (or Generator) U.S. EPA, ?lumber <br />U <br />1 <br />Cal: Ky's P ;arta: <br />6:or h lay Y9,11 <br />18c. Signature of alternate Facility (or Generator) <br />Q <br />a <br />+g. Hazardous 6v;vsle RepertManagement Method Codes (i.a., codes fcr tazardous waste treatment, disposal, and rec/c!Y'.9 systems)C <br />t 2 3. 4. <br />20. Des;gn+ted Faahty Caner nr0 eratnr carnification of receipt of hazarlous materials covered by me maWest except as noted in item 16a <br />gnature Month Day Year <br />°rrr:eC+7ypeo flame r <br />,.,.ulnonn1r rriov <br />EPA Form 871,0.22 (Rev. 3-03) Previous editions are orsoiete.i/ r • n•+•��• — -- <br />