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oo (D o � < <br /> H� <br /> Z3 _. W W O 0 N ZT <br /> 00 (D = 0 O 3 <br /> p rt 10_TYPE=GEN_EPA_IG6id=99 0 0 A <br /> Z <br /> N QJ <br /> n <br /> IM Please pool or type(Fprm eesi ned far use on elite 112-Pilch)Iypewnler.( VIII IlP NI f�l m M W <br /> eoarabr 1p A OMB Numder Fu.^' Nn 2'%+�•,-f:ii <br /> UNlFGRM HAZARD1 G <br /> OUS 2 Paye 1 or T Emergence Rnepanae Phurie /Maldt.1 Track Rumhar wCn <br /> (n WASTE MANIFESTO! i 92821 FLE � � 6 � <br /> 5 GenarzluPs Neme and Mailing Address 11 L v L � � � <br /> Gennrefbrs-o.rt�,,r,_..il,xh,.,,..ihpn mal�nq a�.esr N <br /> 00 00 <br /> —.1 C: 0 <br /> U(+nefalors Phann <br /> b ranspMer wnpany ame i EPA ID Number 0 <br /> Transporter2 Company Name in 0 <br /> __.pPAlfl Num4ar G 7 <br /> a.Dmgnat d FaGldy Name and Ske A:;dr;. U 5 EPA ID Number N) 4h. kv <br /> NCD D <br /> p CD <br /> Facility's Phone. C: U) <br /> ga !3d U 5(JOT Deacnpapn ji-Nding Proper Shipping Name Hacard Class,ID Nemder, 10.Conta,ners ;�Trnai Q CD <br /> riM ni Paaiwg cn•np uranyl) - <br /> a No, Type QuImry C W <br /> O <br /> O � <br /> Z t <br /> 1 - U <br /> D <br /> (D <br /> 0- <br /> a O <br /> 1J Spez,a 1lanninn l>n.keons and Addltlonal lnlonnatlon O <br /> O <br /> ?5 GENERATOR'SlOFFEROR'S CERTIFICATION-I hereby declare that the wnten%gl ihiscmisignmenl arc fully and accuratelydescribed above by the proper shipping name,and arc dassrfied.packaged. 3 <br /> narked and Ia4eledrplarardetl,end area in all respecisin proper condition for transport according fo applira6le International end national govemmenlal reguladons.If eVort shipment and I am the PrenerT ^'� <br /> ESNrfer. c.Rify that i%eonferds cl Ih:s cansgnmenl mnform m the leans of the attached EPA Ackmeiiedgment of Consent 5 <br /> 1 certify that the wask minlmlzagdn siatement�deaofied M 99 CFR 262 27(a)(if I am a large quanily geoenelarl or ICI{,f I am a small quantitygeneratoq Is tine. <br /> enemior .emrs PnoteVypod Narne Signaurs y ym Q <br /> J 16 Internaeunai Shipments ❑ to U.6 <br /> !— ❑Export horn US pwtolerwe.k: <br /> Z— Trans ortw sr newre(fore ore Dale leavIng U.S.. <br /> OC 17 7m-BMFAeluoO&Jpnentof Reca(plor Matanals r-F <br /> msparlea I P' yped Name Sq.wre O <br /> d ' I � <br /> aTmnspor1er2 Pri tCyped Name 51gnature <br /> F <br /> 1 le Dlsumpaw, <br /> 18a.Dlsaepa,,.Irn alio,Spam ❑Quantity ❑Typr ❑Residue ❑Parkai Relecaoo ❑For Repaw <br /> klandest Reference Number <br /> 78G Alteimale Fx,lar lm GanBralorl U 5.EPA1D Numter <br /> J <br /> u <br /> 4 <br /> LL <br /> FacltysPhve <br /> uujj 18c Signalrve 0 AiwTiaM Fadltytw Gerloratx) hk m 0, Twr <br /> Z <br /> ?G Flazardooc Veasle R <br /> ' oom Martagalrlraa Medtpd Coiled{I a,codes far narandous wears treatment.disposal,B'recydkng Syslems'i <br /> 2 3 y <br /> .-.-:1«agnatWo Faday l'lAnrar Crllf�lgn a reeelp!of haZAerdaus meladals mrered by tha manitesl excapl es noted m Ileni 18a x <br /> '-teJ'7ryed Name Signature Ili y yff <br /> (D <br /> <7 <br /> EPA Fo"8T9Q221Rav 3-M) <br /> GNFRATORS INITIALQ <br /> T <br /> CD <br /> ZJ <br /> -P, o <br /> O 01 <br /> 0 <br />