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-...........__-______________--'___ ......'............-____..........__......... ...... ...... ---_ <br /> SH% f5.Generators Name and Mailing Address Generators Site Address(if different than mailingaddress) <br /> � 2�991�712 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZA 1.Generator ID Number 2,Page 1 of 3,Emerpp 4.Manifest Tracking Number <br /> WASTE MANIFEST <br /> Respopse`ho�'�O007314175 SKS <br /> | <br /> Generator's Phone: 4 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 1, UIKLT44 R01,11) <br /> Facility's Phone: <br /> 9a. 9b.U.S.OCT Description(including Proper Shipping Name,Hazard Class,ID Number, 110.Containers 11.Total 12.Unit 13.Waste Codes <br /> HIM and PackingGroup(it any)) No. Type Quantity WI.Nol. <br /> 4", WIRIDF012 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> � <br /> � <br /> ` <br /> | <br /> � <br /> � <br /> ' <br /> � <br /> ' <br /> i <br /> | <br /> ' <br /> � <br /> � <br /> � <br /> l <br /> ' <br /> V � <br /> ` <br /> 15. GENERATOR'S/OFFEROR'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 laboledlplacarded,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 /> Exporler,I certify that the contents of this consignment conform to the terms of the attached FPA 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 /> Generater'si0iferor's Printedfrypod Name Signature Month Day Year <br /> 16.International Shipments <br /> Ll Import to U,S, Export from U.S, Port of entrylexil: <br /> V.Transporter Acl�nowledgment of Receipt of Materials <br /> LU <br /> Transporter 1 Prifited(Typed Name. %Mttlre Month Day Year <br /> ,u> Wra�;spr �8ignature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space 11 Quantity Ll Type 11 Residue El Partial Rejection 0 Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facility's Phone: <br /> Lu IBc,-Signature of Alternate Fac4lly(or Generator) Month Day Year <br /> in— 19,Hazardous Waste Report Management Method Codes(i,e.,codes for hazardous waste treatment,disposal,and reoyding systems) <br /> UJ <br /> 20,Designated Facility Owner or Operator�Certification of receipt of hazardous mate6als covered by the manifest except as noted in Item 180 <br /> Printedrryped Name Signature Month Day Year <br /> EPA Form 8700-22[Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> � <br /> ` <br /> | <br /> | <br /> / <br /> ` <br /> i <br /> ! <br /> ` <br /> ! <br />