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0 9 <br />Please print or Woe. (Form designed for use nn N. 112.:o -w i._e,...o., s <br />1 )145''41 /150135 DcEll UNAI MU rACILI I Y IOidCNERATOR STATE (IF REQUIRED) <br />l <br />- 111.1"'"' Form Approved, OMS No. 2050.0039 <br />UNIFORM HAZARDOUS 1. Generalor lONumber 2.PagololJ. Emerymry Res n phone 4, Madlool Tracking Number <br />I:ADi9::'.7 r! .y <br />,`.ci1 1so <br />.('•;til . j0 <br />WASTE MANIFEST •�.:? <br />l SKS <br />5. GoneNV I;kl.ill? '1 AIC Nameend Making Addressn <br />W1�;1�: ns Generalors the Addrose(it dl0emnl Than meting aaaresq <br />Genemmis Phone: e0 '�•-�''/,•.,;1 f 1 <br />flTranapoGell Company Name <br />i. I* L.16.[.11 Sr!. fF";C4' .;,1' U.S. EPAID Nundmr <br />7. Tmnspwlef2 Company Nano <br />U.S. EPA ID Number <br />+ <br />B. DeslgnelM FodBry Name and SileM"", 3AFlETY--KLEE"11 SYSTEPIS,,Q1(;. • US. EPA ID Number <br />6000 881'R 5TR5FT <br />SACROENTf1 1q glS.a2y <br />9.t h-;4it , -•191 <br />FedLNs Phone i-A')tf (i408 q ;1 <br />90. <br />9b.US. DOT Description Pmpar Shipping Name, Helena Class, ID Number, <br />10.Conithans <br />HM <br />and Packing Gmup(Nalrh) <br />11. Taml <br />Quantity <br />12. Unit <br />WIN01. <br />iJ. Waste Codes <br />No. <br />Type <br />1'NUN-�RCRA <br />m <br />HAZARDOUS WASTE.;, <br />(Af11JE0U£ PARTS UAS14ER GULUTIUPI) <br />� <br />z <br />u <br />3. <br />4. <br />14. Special Hentllip NaWctio¢s and Addiwnal lnmmle8on <br />SK SN1P4ae*40&ti4 SoEor, 8rao 3714SE, 2, C5:0101.' <br />r r r e! Ij: Y_'a' <br />tiro)z69 <br />N HR E11_EN(iEhICY q 800-468•-1/60(SAFETY-RLEEN - '94158) <br />v <br />-AGENERATOR'S!OFFEROR'SCERT'rl AIlON:Ihembydedero 9ud9,ecentenwdlhlsconoymanlaw <br />I6. <br />fid eMetammrydasan'hetleebova hyNe proper shipping namo,eM em da1N8e9, <br />marked and bbolMlplsurded, and are M al mPeds h properceMiBdn forherspod ecmrdngtoappgoshm <br />Imm ikmand material governmental mindosions. 11 avoid shipment and I am the Primly <br />EaPonen I cerGry Nal the coments of(No comiti mill conlotm 10 he 1,05d0e attached EPAAdm..ledpmentolConsam. ry <br />IcaUrydwt me N810 mlNmdulon stidemant ldenlMed In 40 CFR 28227(,) (K l em a lw90quantity gmemtor) w(b)(dlam aero B Ie one. <br />Gen mmrny08o PMlad/Typotl Nam, Sip Tum <br />Month Day Year <br />..r 16. In omeuaw 8 man <br />❑Impodto Uyq. ❑ Export koro US. Pwial enby/edh <br />WvMpdglaponoanry): <br />Dalai" PUS -- <br />I7.TmmderefA <br />g 11.TmmpMerAtlmpy4eawneN ofRacelpidMemdam <br />T <br />0 ➢anspo 1 Pdn N SlgnaWm <br />Is. Marsh Dey Yeer <br />w I' <br />T r2 PdmaNTyped e k.( �2. y U <br />e <br />rc month my Yews <br />1 <br />ADiscrepanq <br />f <br />Ifla. Discrepancy Indication Space ❑ Quan9ry ❑Type ❑R.1d.H ❑Padml ReJecllon ❑FWIfleJepion <br />18b.Alternate Facility (or Generator) MaNBll Rderence Numaw: <br />U.S. EFNID Nunbar <br />U <br />ILL <br />FacaYs POona; <br />w <br />Tec. Signature olAgemale Fedsly (er GenomloQ <br />6 <br />Monro flay YOU <br />z <br />h19. <br />Hezaraouc Wazle Rapod Mmagemenl Method Coes(I.e., cedes lw haierddowere ueabnent, disposal, and mcydng syslemal <br />t' <br />f 2 3. <br />1 20.De gnaled FOckyOng parawt. Certification armcep ousmaludds oamd By NamBrc ad ex apluntletlNllOm1BB <br />nledrTyped Name <br />na m <br />' MwN % set <br />ce <br />PA 4 <br />Form 8700-22 (Rev. - 1 PreWous edlliens ars nNnlmn Z7 TIJ <br />1 )145''41 /150135 DcEll UNAI MU rACILI I Y IOidCNERATOR STATE (IF REQUIRED) <br />l <br />