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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page I of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 1006462950 SKS_ <br /> 5 Generator's Name and Mailing Address Generator's Site Address(I different than mailing address) <br /> 1 1�,F, Fast Pine Ft. <br /> Generator's Phone: W)I <br /> 6.Transporter I Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> FAN HAR50k,13 MikONVINTAL SVG !NC. <br /> 8.Designated Facility Name and Site Addr r' CLEAN HAOURS iBPA Jihil: U.S.EPA ID Number <br /> 1,111F.1 BERRYESSA ROAD <br /> SAN ME C-A 9513.3 <br /> Facility's Phone: 406-44 1-1196P. r CAD!211594943TO <br /> ga. 9b.U,S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity wtivoi, <br /> Ce NON RCRq HAZARDOUS WASTE'. 90[ 103 <br /> 0 <br /> (DEBRIS, PETROLF-11M HYPjRrX:4R6CINS,15 <br /> L <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 15.` RNEitER:55'FER"6;'S CERTIFICATION:1;r_ ydacrwe that the 7.6fentNfthi's consignment are Ulyalndtitc7rNly described ab6V6'by'7t6Q9Wih?pping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects 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 attached 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 /> Generatoes/Offeroes Printed/Typed Name Signature Month Day Year <br /> _J 16.International Shipments' <br /> ;w_ 1:1 Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> LW17.Transporter Acknowledgment of Receipt of Materials <br /> Li <br /> 6i Transporter 1 Printed[Typed Name Signature Month Day Year <br /> 0 <br /> CL <br /> d/Typed Name Signature Month Day Year <br /> Ce <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity ❑El Type El Residue El Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Adtemate Facility(or Generator) U.S.EPA ID Number <br /> :3 <br /> LL Facility's Phone: <br /> LJin <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UJI 1 2. 7. 4. <br /> 0 1 1 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />