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Please print or type.(Form designed for use on elite(12.1 ypewriter.) Form Approved.OMB No.2050-0039 <br /> TUNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C L 4��1 .g 1-`, 1 1 1.• �00- 4,8. 1 l A) 002 08266 SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(If different then mailing addresa) <br /> Generator'sPhono �' tr <br /> 0.Transporter 1 Company Name U.S.EPA ID Number <br /> :1'„ ..a:4 :r:ri <br /> 7 Transporler 2 Company Name U.S.EPA ID Number <br /> 8 Designated Facility Name and Silo Address r U.S.EPA ID Number <br /> Focilit es Phone: ( ''" '!'X D0T/6 p; !2 <br /> ga. 9b.U.S.DOT Description(Inducing Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM ares Puuking Group or any)) No. Type Quantity WI.Nol• 13.Waste Codes <br /> 1. <br /> o ;�.�r ':4i `�a.3.,:�s:%! }��tY #�� �I. 3 tJfri f <br /> 11007 "v,i AMl; <br /> Z 2. <br /> W <br /> C7 <br /> 3. <br /> 4 <br /> i <br /> 14.Special Handling Instructions and Additional Information (t,.r"r:• ,) <br /> �,-. <br /> :fa.r <br /> i' crit. i;1 :i•t>�,turf)"'1 60 Va,O F;TV::Ktff—Al 94131 <br /> 15 GENERATOR'SIO PEROR'S CERTIFICATIONi 1 h'.db debit 1)idl'ihb�nib tis'1!ttifa §Ig exit r•f"ully • c rill lyrd b dab b proper shipping name,and are classified,packaged, <br /> marked and labeiedlplocarded,and are in all respects in proper condition for transport according to applicable Intemetionalend national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I coNfy that the contents of this consignment conform to the terms of the attached EPAAcknowledgmenl of Consent. <br /> I curtly that the waste ndnhnlzaUun statement Identified In 40 CFR 282.27(8)(if I am a large quantity generator)or(b)(If I am a small quandry generator)Is true. <br /> GeneratoeslOfierors Printed/Typed Name Signature Month Day Year <br /> 16,International Shipments �" -•' i °" `^' ; <br /> F— ❑Import to U.S. ❑Export from U.S. Port of entrylexik <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> LW 17.Transporter Acknowledgment of Receipt of Materials <br /> OTransporter 1 Pnnled(fyped Name Signature ,,L,y ' ti �,'—,-,' f J Month Day Year <br /> CA <br /> Q Transporter�PnrdedlTypedName I SlgnBtD Md t 90 ftw <br /> oa <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quenlityyp } ❑ <br /> ❑T e Residue Partial Rejection Full Rejection <br /> ` Manifest Reference Number: <br /> 18b.Altornato Farallty(or Genorotor) U.S.EPA ID Number <br /> J j�. i• <br /> ud- Facility's Phone. <br /> W 18c.Signature of Alternate Facility(or Generator) j >: Month Day Year <br /> Z <br /> 18,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous wasteiyeartmentAitposal,and recycling systema) <br /> o t. 2. 3. 4. <br /> 20,Designated Facility Owner or Operator;Certificatlon of receipt of hazardous materials covered by the manifest except as noted In Item 18a <br /> riedfTyped Name Signature Month Day Year i <br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> Z'd 22t7289`1 :01 )------09OSS28602 i' ),umoNDfldl -1­130NU..:WOdd J20:20 0 02-ZZ-d9S <br />