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Please pi hi or type, Fonn Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDO <br /> us 1.Generator IU Number 2,Page j of 3.Emergency ResponsePi-one A <br /> "T-Manifest Tracking Number — <br /> I <br /> WASTE MANIFEST <br /> - . �: ­ � -Z' 1 9 1";I-e'-,�7 7,��, 1- 022830388 JJK <br /> 5.112pnerato(shamo and Mailing Addross Generator's Site Address(if different Iran rnal!ing tiddress) <br /> Gorlarato?sphonL7 Q� <br /> 6.Transporter 1 qx6pwy Name <br /> U.S.EPA 11)Number <br /> 7.Transportet-2 Coll)aily arnp <br /> U.S.EPA fl)Number <br /> CA� `el- -) Q-`_0 <br /> 8 Oes�,pqtqd f.�cility Name aqd Site Address US,EPA ID Numb <br /> ;% <br /> Facitty'aphone: <br /> 9b.U,S.DOT Description;including Proper Shipping Namehazard Ciass,ID Number, 110.Containers 11,Total 12,Unit lVArasle Codes <br /> HM end Packing Group(if any)) No. Type Quallf,1Y WOV01. <br /> ? <br /> pc C <br /> 00 t 16 X( <br /> T7- <br /> W <br /> 0-0 <br /> 4. <br /> 14.ji94F4andllrq Instruclionz andkldlfiorfaLln(urr,iliuft <br /> 7 <br /> 15. GENERokTOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the writerb of this consignment are fully and accurately desabed above by the proper shipping name,aniare classified,packaged, <br /> marked and labeflediplar arded,and are in 3;1 respecm in proper wndition for transport according to appl;('ab'.e internatfonal and national governmental regulations,If export aIiipjnent and I am the Primary <br /> Exporter, <br /> -I certify that the contents of this con5ignment conform to Ilia terms of the attached EPAftnowledgirent of Consent. <br /> I ceilFy lhai:he waste minimization statement identified in 40 CFR 262.277(a)(f I act a large quantity general r)or (if[ams small quantity genara[V)is true. <br /> Gener s,'Offer;rs PrintedlTyped Name Signature Month Day Year <br /> j <br /> -a Shipments Import to U,& ---LZ-L/-12-1L Z2 <br /> F]Export from U.S. Per*of antryiexit: <br /> Transporter signature(for exports only): xr Data leaving U.S.: <br /> 17.Transporter Acknowledgment of Recolpt of hia-i.ehals <br /> LU <br /> Transporter 1 Pdnted,'Ty d ne SignatureMonth Day Year <br /> Z Transporter 2 Printed[I-yp f,4 le0 5i:n litho Month Day Year <br /> 6,e <br /> 18.Discrepancy <br /> SSS 18a,Disrrepairicy Inuicalien Sp". Quantity OTYPF 1.1 Residue ❑Partial Rejection Full Rejection <br /> Manifest Referenco Number: <br /> I Bb.Aiternato Facility(or Generator) U,S.EIPA ID 1`"Irnber <br /> i<1 Facility's Phone: <br /> ft Signature of M <br /> tomato Facility(or Genera , Month Day Year <br /> Kt <br /> ;Z <br /> 0 '19.Hazardous <br /> �Fj — ou Waste Report Management Codes(!,a., WaFletreatnient,disposal,and recycling systems) <br /> 2. T <br /> .............. <br /> 20.Designated Facility awiet or Operator:Cerlificaijon of receipt of hazardous materials covered by the manifest except as new in Item 1 as <br /> FnatpOr I yped Name Signature <br /> Mont 'j, Yea <br /> -r <br /> EPA Fenn 8700.22(Rev,IT-1 7) Previous editions are obsolete. X - DESIGNATED FACILITY TO EPA's �-M.ANWEST'SYST7,� <br />