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May051603:43p King Island Enterprises 20ig7-4364 p.7 <br /> Pleaseptintorrype. Farm designed for use on dile(12-pitch)typewriter.) <br /> I.Geiemtor D Number Form Approved.OMB No.205W39 <br /> UNIFORM I MANIFEST FtD0U3 2.Page 7 n! 3 Emergency Response Phone 1.M TmeNlre Number SKS WASTE MANIFEST . .. . : SKS <br /> 5.Generaols Name anti MailingAtldmss - n <br /> Gansmods sial rens(ddgMrad manmellurp—a m) <br /> Geremors Rrax: <br /> S.Tmrv;odtr 1 Comp'"Name <br /> . .. .. - _ US.EPAIDNumcer <br /> 7.TransoorW2 Compaly <br /> U.S.EPA ID Nunber <br /> 9.Designated Fedry NimeadSMeAdiress .. ........., <br /> _ - U.S.2PAID Nunber <br /> Fad6l is Phone: - .. . <br /> ga. 30.U.S.DOT I)mCnpfion rrrrJ d g Fboper Sryloping Nacre,HazardCbas,ID Nmrber, iD.Cmtairem <br /> HM aid PaGdng GMA(If any)) 11.Tolel 11.Urd 13,'Haste codes <br /> No. Type Guar* A1.1vol. <br /> Or <br /> W <br /> Z 2. <br /> W <br /> U <br /> 3. <br /> 4. <br /> M Y 0 5 2016 <br /> 14,Soedal Handl ng lnsmrEons antlAddlivmlln(ermeeon <br /> 15. 6ENERA7oPVFFER5RSCERIIFICATI0N: 111erebydeowa tial me mntenfS Umis conslAnmmt 11051y and axumiieydasahed Blom by me piopxshipping name,atle:e classfiea,packaged, <br /> marked and l3beledI WWI min dI respells in properoondaon for banspn aoo0rdbg to applialbb intemaforel and naioral lyemm nbaI mguladom,If export slapmertand I sn ins Primary <br /> I5lmter I(eddy that the eomenta 01 this amsiprimant cadcTm to the tennanf meattl EPAAcknw Iedgmentof Consent, <br /> bartiII"Waste nRamiratlon statement identified In 40 CFR 262271a i(if I am a lagequangy generator)or(5)PIN am a small.quandly gonerabr)is true. <br /> Ge�nBratar'srORerg(s.PrFdedriypBd Name _ Signature i,- Day Veer <br /> F 16.IntemafionaiSHpmeNs :"".::,,••.`-, . <br /> ❑Impmto <br /> ❑ <br /> U.S.' Expos from U.S. •, Ppnofai4y/mdi, <br /> T'ansporbr signature(for Exports o'dy): Date leaning U.S.: <br /> W 17.TranspSRe•.Acknwdedgmam offacaptoi Malell <br /> Tmreponeri RhMd/ryped Name;' - Sgrehle- . <br /> O March Day Year <br /> Transpatar2 RlntadRyped Na ' ' Slgm�l're Morah >Day ,Year <br /> Y 18.gecreperwy <br /> T 18a.Discrepancy Indication Spee, ❑ Ouanty ❑Type ❑R.don ❑Partial Rnedmn ❑FUI fiOacdon <br /> Manifnat Reference Number <br /> 13b.AMarnam Facfidy(a Genembr) U.S.EPA ID Numbsr <br /> v <br /> LL Fadlly's Rona: <br /> w IBn SignaWre cfAVrle Feciiy(a Gene'aod Day Year <br /> G Match <br /> 2 <br /> H19.4uardous Wash Report Msnagemad Metod Codes(z,oodea or hararftM%Vaste ireahnert,disposal,and reerdirg systems) <br /> A <br /> F <br /> 1 20 Desgnaetl Faolry0wnarorOpembr Cem7caaon ofrewlp aFhawtlousrrelaiabv-ryorrd bgme madfest exceptasnuNd in Item lea <br /> PnrbdlLmed Mare ;.,t ssneturo MadryDay Yew <br /> EPA Form 970522.(Rev 3-05) Previous editions are obsolete. 7ESIGNATE6=AGILITY TO GENERATOR <br /> I <br />