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11. • • Please print or type.(Form designed for use on little" ittle(12-pitch)typewriter.) Farm App,oved.ONE No,205M039 UNIFORM HAZARDOUS 1.Generator ID Number 2,Page i of '3 Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST - - e SKS �V C� 5.Generabrs Name and Mailing Address General Site Address(if different than mailing address) 671 67 Generators Phone' 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8,Designated Facility Nam,and Site Address U.S:EPA ID Number Fedll ys Phone: ge, 9b.US DOT Desniti(including Proper Shipping Name,Harem Class,ID Number, 10.Cartel am 11,Total 12.Unit HM and Packing Group(if any)) Na. Type quantity Al 13.Waste Codes E f w t w 2. 3. 1 I � 4. r i 16.Special Handling Instructions and Additional mansion 15, GENERATOW&OFFEROR'S CERTIFICATION: I hereby declare that the contents of this cansignmenl are fully and accurately described above by the proper shipping nems,add are classified,packaged, marked and labalediplararded,and are in all respects in proper condition for transport according to applicable international antl national governmental regulations,If export shipment and I am the Primary Exporter,I deal that the contents of this consignment conform to the tens M the attached EPA Acknavledgment of Consent. I sandy that die Made minimization statement identified in 40 CFR 262.27(a)of I am a large quanthy generator)or(b)(If I am a small quantity generator)Is trpe. GeneratarslOffewl's Pdnlad/Typed Name n Signal Month Day Year SV ," 18,International Shipments F ❑Import to U.S. ❑Export Som US, al Pod of entryle R z Transporter signature(for exports only): Dale leaving U.S.: w 17.TransporerAcbwwledgmenl of Receipt M Materials OTranspoderl PdmedtTyped Name Signalure Month Day Year H .� Transporter 2 Pimud(ryped'Name Signature Month Day Year } 18.Discrepancy 18a.Discrepancy Indication Space ❑quasi ❑ ❑ 1 ❑Full Rejection ty ❑Type Residue Pallial Reaction 18b.Allernele FaalBy(or GenerelorJ Manifest Reference Number: J U.S.EPA ID Number U uii Fedlibre Phone: Ido.Signature of Alternate Facility(or Genemror) Month Day Year 2 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and racyding systems) al. 2. 3. -T- 20. 20.Designated Facility Owner or Operate'.Celafication of receipt of hazardous materials covered by the manifest except as noted In item 1 B PrintelTyped Name Sigaaturs Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY