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Please print or type.(Form designed for use on elite(12-piipewdtec) If Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number t 2.Page 1 of 3t�jggr M1cy(est seiPl7on�,. 4.ManHesTrzcking Number <br /> WASTE MANIFEST 002830197 SKS <br /> 5.Generators Name and Mailing Address Generators Site Address(a diffemnt than mailing address) <br /> Generators Phone: <br /> 6[ranaporter i CompanyName U.S,EPA 10 Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address I;U.S..EPA ID Number <br /> Facility's Phone: <br /> ga gb.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers it.Total 12.Unit <br /> HM and Packing Group(If any)) 13.Waste Cedes <br /> No. Type Quantity WWoI. <br /> 1 rif;tV ' .iT <br /> Z 2. <br /> W <br /> 0 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> rr.-� .. ... <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of This consignment are rely and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all tespecls in proper condition for transport according to applicable International and national governmental regulations.if export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the allached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified In 40 CFR 262.27(a)(If I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Ron ratorslOBemrs Printed(fyped Name Signature Month Day Year <br /> r <br /> 16.International Shipments <br /> Z ElImport to U.S. ❑Export from U.S. Por[of srsylexit <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.TranspaterAcknowledgment of Recegtt of Malan <br /> Transporter 1 Pdnted(Typed Name ( Signature Month pay Year <br /> Transporter 2 Pdntedrfyped Name - Signature Month Day Year <br /> K <br /> i-- <br /> 18.Dlsciepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Residue <br /> Type ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA 10 Number <br /> zi <br /> U <br /> LL Fadlitys Phone. <br /> 18c,Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item tea <br /> Printed7ryped Name Signature Month Day Year <br /> EPAFom1.8700-22(Rev.3-0b) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />