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Please print or type.(Form designed for use on elite(1&pitch)typewriter,) <br /> Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS T Generator ID Number 2 Page 1 of 3.Emegerxy Resp Phone 4.—manifest Tracking Number <br /> WASTE MANIFEST - .. _ ..• SKS <br /> S.Generators Name and Mating Address Generator's Site Add s(I different than mailing address) V„t7 <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA IO Number <br /> 7.Transporuw2 Company Name <br /> U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facil es Phone: <br /> 9, 96.U.S.DOT Description(including Roper Saipplig None,Houam Can,ID Number, 10.Co more 11.TOlal 12.Unit <br /> HM and Packing Group(if any)) M.Waste Codes <br /> 1. <br /> Na. Type Quantify V4'bVOL <br /> a <br /> O <br /> z 2. <br /> w <br /> x.7 - <br /> 3. <br /> 14, <br /> 14.Specs Handling Instructions and Additional Informalior <br /> 15. GENERATOR'SIOFFEROR'S CERTIRCATION: I hereby do,-Are that the contents of this xinsignmerc me fully and accurately nbed above by the proper shipping now,ard are classified packaged, <br /> marked and labeled/placarded.and are in all.•cspects in proper condition fm lranspo.4 arrordinn to applicable inlernadoral and N Deal governmental regulations.If export shipment and I am the Primary <br /> Exporlen I candy that the contents of this consignment come"to the Imms of the attach"!EPAAcknmeiedgment of Consent. <br /> I certify that the waste minimization saleroom identifier In 40 CFR 26.2.27;x)(if I am a large euald ly genemtoq or(of(f I am a sn II quantity generator)is me. <br /> Generatoes;Offerors PnnleMyped Name Signature Month Day year <br /> 16.International Shipments —I <br /> Exp <br /> ❑Import to U.S. `, od horn 11.5. Pon of a gSoxic <br /> ? Transporter signature(for exports only): Dale lea it;U.S.: <br /> w 17.Transporter AcknoMettgment of Receipt of..kAlwals <br /> OTransponer l Printedrryped Name Sgnalure Month Day Year <br /> n <br /> rq <br /> Transporter 2 Pnnledrryped NameSi gnaWrc nth MoDay Year <br /> C <br /> r <br /> } 18.Discrepancy <br /> 18x.Discrepancy Indication Space ❑ Queerly ❑Type I.�Residue ❑Partial Refection Full Rejection <br /> I8b.Alternate Facility(or Generator) Manifesl Referelc umber. <br /> J U.S.EPA ID Number <br /> V <br /> r+¢- Facility's Phone: <br /> OW 18c.Signature of All"nate Facility(or Generator) Month Oay Year <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes Ox. call for hazardous waste treatment.cisposal,and recycling systems) <br /> � 1' 2' 0. 4, <br /> 1 20.Designated Facility Owner or Operator.Certification of receipt a'naeardoux materials wvnrad by the manifest except as noted in lie 6a <br /> Printedrryped Name —sig-tum, Month Day Year <br /> EPA Form 870D-22(Rev.3-05) Previous editions are obsolete. <br /> r <br /> E 'd <br /> 2990-Sb_ 60Z ge2ueW FggoH eSZ :60 LO 22 ueW <br />