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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 1 of 3.Emergency Response Phone 4.Manifest TreckNumber <br /> WASTE MANIFEST Cts, t i t 3r't cl1 ► 1-800-46il-1760 002908266 SKS <br /> 5 Generators Name and Malting Address Generator's Site Address(if different than malling address) <br /> 'vxk4a <br /> aL�FI �3��76 <br /> Generator%Phone! •=' j'' ' <br /> 6.Transporter 1 Comparry Name U.S.EPA ID Number <br /> 1...iti -YU1't61+vu 114; TXft180 54i 30 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> x e - !!�/ <br /> P Designated Facility Na=aha Site Address C-AFETY—ALIX-14 SYSTEMS INC. UjQA1113 Number <br /> 222 GI:rC PER CRM 9MD <br /> Facility's Phone. ' 'r� w TX 76268 `I`XD077603371 <br /> 9a. 9b.U.S.001 UoscdpUon(including Proper Shlpping Name,Hazard Gess,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol, 13.Wegte Codes <br /> rY _. 1 : -t'c i''h1:tn7� (I'i ..t''�ltk V'lir�•� �1��...�'1 ,:r DM P D001 DQ05 X06 <br /> O ' a irr1 <br /> D2107 213 HITS <br /> w <br /> c� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> tiK <br /> .30705767 t �70�7fi CSG t; , <br /> --1?6w (SAFETY--KLEEN — 94138) <br /> 15. GENERATOR'3100Ft R0 ' ER FIQ . ere y der are hal ' con en e o hila con gnmen are ly an accu y carr a ova y ,a proper shipping name,and are classllletl,packaged, <br /> marked and labeled/placarded,and are In all respects In poper condition for transport according to applicable International and national governmental regulations.If export shipmehl and I am the Primary <br /> Exporter,I certity,that the contents of this consignment conform to the terms of the attached EPA Acknowledgment 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 /> GeneratorsfOfferor 9 PrinledlTyped Name Stg ture • MWIPL Day Year <br /> 16,IMernallorial Shipments t !❑ "---� <br /> Impod to US. Expert from U.S. Pon of entrylexlk <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> aTransporter 1 Prinledrryped Name Signa Month Da Year <br /> 4��r- 'CL"v% <br /> O - <br /> 74, Tran"(w.2 Printedfllyped NemB-" Slgnatun Mo ay Year <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space ❑ Qumtity ❑Type ❑Residue ❑Pertlal Rejection ❑Full Rejection <br /> Menifee,Deference Number: <br /> 180,Alternate Facility(or Generator) r U.S.EPA ID Number <br /> J <br /> V <br /> FaCility'6 PllOne; <br /> OL lac.Signature of Alternate Facility(or Generator) Month pay Year <br /> Q <br /> 2 <br /> 19.Hazardous Waste Report Management Methal Codes(i.e.,codes for hazar4ous waste treatment,disposal,and recycling systems <br /> 20 Designated Facility Owner or Operator Certlflcationof receipt of hazardous materials covered by the manifest except as Wed In Item IBe <br /> PrintedrTyped Name ` Signa re Morrilti Day y6fv <br /> A( is 1 of 'Rif <br /> EPA Farm 8700-22(Rev.3.05) Previous editions are obsolliiite. SIQN FACit."Y G'gN R R <br /> 8'd 22t7289t7t01 )------090SSE86o2 i, At1mdNDn1 ji -1-130NdA:W06J dt70:20 OT02-22-d3S <br />