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I 1 4i^7" <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />Form Annroved- 0MR Nn 9nsn-nnnl.Q <br />E!A�Forrn 8700 -2 -(ti& 3-0§) Previous editions areolfso N968MMATIED MCILITYTO DEJ91NATION STATE (IFREQUIRED) <br />UNIFORM HAZARDOUS <br />1 11. Generator ID Number <br />r -f -1110 lb 7 7 1. f'.. 0, 6 <br />2. Page I of <br />3 Phone <br />pei.l? L <br />7002184104 <br />Manifest rac ng Number <br />SKS <br />WASTE MANIFEST <br />5. Generators Name and Mailing AddressGenerators Site Address (If different than mailing address) <br />ii NI; Lli%IEES !MC, <br />DOPNO 13 <br />.A CA5206-OMS <br />Generator's Phone: <br />6.'[r ff �qpR Ua�Mffe BBS TEM -3 U.S. EPA ID Number <br />7. Transpoder 2 Company Name U.S. EPA ID Number <br />T d 9/- <br />B. signaled Facility Name and Site Address3n1r-*ETV---K! !"IED.1 SYS)TEK-L INC. 71, U.S. EPA ID Number <br />1722 COOPER CEK REr[j' <br />ln.47-om. I T-1% 78200 <br />9:11ki-483-5200 TH077603371 <br />Facility's Phone: <br />9a. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, 10 Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WtJVbI. <br />X <br />I- Ff--i t,IPSTE* N. 0. S. <br />Wil <br />21.�. <br />0 <br />MIJ-993 PS ill (DOOD. <br />36C, <br />Z <br />2. <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information 8<' sNIPS'22000758Q-!371121 <br />D U"131" 123 <br />elk HR EMEIRGENCY 4`1-800-468-1760 (SrIFETY-KLEEN - SIM38) <br />SK AUTH"D TO USE SUBS EQUENT <br />15. GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping 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, f certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certily, that the waste minimization statement Identified in 40 CFR 262.27(a) (if I am a large quantity gerierator)2!(if I a m a small quantity generator) is true. <br />I <br />s PrInted/Typed Name li,naUMonth Day Year <br />-J <br />16. International Shipments El import to U.S. E:IExport from I if Port of entry/exit "IV <br />Transporter signator 3its only): Date leaving U.S.: <br />17. T rlerAcknowledgment fReceipt o Materials <br />Month Yea <br />spoder I Prin d/Typ ate �y ea r <br />0 <br />4Year <br />Transporter 2-P-rinledlTyped Narl✓Re Signature Month Day <br />5C-1 <br />18. Discrepancy <br />118a. Discrepancy Indication Space 0 Quantity ❑ Type ❑Residue Partial Rejection El Full R.jectkin <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />:3 <br />0 <br />tai <br />Facility's Phone: <br />18c. Signature of Alternate Facility (or Generator) <br />cnG, Day Year <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />us <br />1.\ <br />M�02 <br />2. <br />3. <br />4. <br />20-.De gnated-FaVity--wner-or-OperatorrGertifiSatiop-of-recoipt-ofhazardousmaterials-covered-by-Oie-manifest-"as-nded-in-ite2Q8a:=z-A4 21" <br />PrintediTyped)e�jSign re n Y <br />E!A�Forrn 8700 -2 -(ti& 3-0§) Previous editions areolfso N968MMATIED MCILITYTO DEJ91NATION STATE (IFREQUIRED) <br />