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10-08{-' 09 12:45 FROM-saftey-kieen 9163864916 T-0471 P002/002 F-115 <br /> Please print or type,(Form designed fer use on elile(12-pitch)lype riter.) Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.GenoralorlD Number 2.page�101 3.Emergency Response phone A.Manif�st Tracking N <br /> umber <br /> WASTE MANIFEST <br /> ! J. SKS <br /> 5,Gqqatqly(s Nnpiq.and Malliop Address Genersto(a Site Address(iftliffaiem Mn mailing address) <br /> :5 <br /> reneralors Phone: <br /> ary(Jame. m <br /> U.S.EPA 10 Number <br /> 7.Transpoi ief 2 Company Name U,S,EPA 10 Number <br /> 8.Designated Facility Name and SileAddtass seAl�s-% 'x'l U.S.EPA ID Number <br /> T <br /> 7 <br /> Facility,"Fborw: <br /> qa. 9b.U.S.DOT Description(inotuding Proper Shipping Nome,Hazard Class,ID Number, Contaf efs 11.Total 12.unit <br /> tIM and Packing Group(it any)) • <br /> No. -j--Ty-pe-] QuandLy Vyt./Vol, 13.Waste Code. <br /> rig, - - '.) '...: - .. ' <br /> "V1400L.4)l Ut 'f'r P.),7 r 6 i 1 <br /> :.+-1:T :l <br /> LU <br /> L9 <br /> P, <br /> 15. GENERATOR'StOFFERORIS,CERTIFiCATION: I hereby declare that the contents of this consignment are fuVjard accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledfplacafdW,and are in aft respects in proper condition for transport according to applicablo international and national goveinmemal regulations.If export shipment 8AJ I am the Primary <br /> Exporter,I codify that the contents of Ilils consignment conform to the terms of the attached EPA AcUoydMUment of COMM <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(8){If I am a large quantity generator)or(6)(10 wn-a small quantity generator)is true. <br /> Generalo(effifferor's Pfirlteel%ped Namc signalvre Month Day Year <br /> + <br /> -J16.Inlemalion3l Shipments <br /> 1�- El Import to U.S. ❑E'po'l from U.S. Pon of enury/exit <br /> Tiansporler signature(for exports wily): Data[saving U.S.: <br /> 17:Transporter AcknoMeOgratnt of Receipt of MabMat,3 <br /> LU <br /> Tran spotter 1 pft yped Name Signature <br /> Month Day Year <br /> 0 <br /> Tranzp6iler 2'P6nI4d/Iypvu Name �"ignaiureMonth Day Year <br /> cl! <br /> Discrepancy <br /> 18,9.Discrepancy Indicalion Space <br /> E] Qu3rtlity ❑Type ❑Residue y Partial Rejection EIFug Rejection <br /> Manifest Reference Number: <br /> 18b,Alterviate Facility{or Generaloi) U.S.FRA 0)Number <br /> Facility's Phone: <br /> -18c.Signature 0AIlemals Farifily(or Generator) Month Day Year <br /> 19.Hazardous Waste Repon Niinagornenj method Codes(i.e.,vDdtu for hazardous waste treatment,disposal,and recycling systems) <br /> 3. <br /> 20.Designated Facilay Owner or Operatic:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pnnted[Typed Name Signalu M61191 Day Ye <br /> r1 <br /> EP6, .orM�7,00-22(Rev.3-05) PreVious eqiji�ns are obsoJete. DESIGNATED FACILITY TO GENERATOR STATE(IF REQUIRED) <br /> !, ?Is,"-, 'y�1 r!) 11 Q1 I <br />