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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number SKS�+ WASTE MANIFEST 100652^ 7 i 6 c Vfid67✓ 4 4 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phone. 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Sile Address r I U.S.EPA ID Number Facility's Phone: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 3.!r:'sste=:cries HM and Packing Group(•f any)) No. Type Quantity Nl+Vol. 1. z 2 W 3. IS IL 1111� 0-0 IF 1111.111111119 U APR ?018 4. ENVIRONMENTAL HEALTH DEPARTMEN 14.Special Handling Instructions and Additional Information 15. GENERATOR SiOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name.and are classed,packaged, marked and Iabeiedrplacarded.and are in all respects in proper condition for transport according to applicable intemabonal and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terns of the attached EPAAcknowtedgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(x)(if 1 am a large quantity generator)or(b)(f I am a small quantity generator)is true. Generator'sfOgeroes PrintedfTyped Name signature Month Day Year .j 16.International Shipments r- ❑Import to U.S. ❑Export from U.S. Port of entrylexit: z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedlTyped Name Signature Month Day Year O a QTransporter Printed/Typed Name Signature "Ia>t Dnr Yo2r H 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue El Partial Rejection Ll Full Refection Manifest Reference Number. F 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Facility's Phone: W 18c.Signature of Allemate Facility(or Generator) Month Day Year Q z N19.Hazardous Waste Report Management Method Codes(i e.,codes for hazardous waste treatment disposal,and recycling systems) 0 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedlTyped Name Signature Monti Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENEk.TJOH . ,141 1 IA,COP Y