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Please pont or type./ 0 0 6 7 7 6 2 9 3 S K S <br /> UNIFORM HAZARDOUS 1 Generamr ID Number 2.Page 1 of 3.Ema Res Form Approved.OMB No.2050-0039 <br /> WASTE MANIFEST 1 - i I-A rAonge,Phone 4.Manifest Tracking Number <br /> 5 Ge_nerator's Name and Madmg Address <br /> = ` 'y 06776293 SKS <br /> Generatoes Site Address(if diBerent than mailing atltlress) <br /> VO <br /> z. t <br /> Generators Phone -'= =•: , �_ _ <br /> 5 Trapspprler l Company�Name <br /> - - U.S.EPA ID Number <br /> 7.Transporter Company Name - <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> �.v � 't F��r -�• U.S.EPA ID Number <br /> Facility's Phone <br /> ga 9b U.S DOT Description(inducing Proper Shipping Name,Hazard Class,ID Number, <br /> HM an Packing Group(if any)) 10.Containers 11,Total 12.Unit <br /> 1 _ r _ _ No. Type Quantity WLNaI. 13 Waste Codes <br /> K <br /> O <br /> U <br /> Ulu <br /> M z. <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information -- / <br /> 15 GENERATOR SIO PFEROR'SCERTIFICATION. I herebytleclare that the contents of this consignment are fully and accurately tlescnhed above by the proper shipping name,and are classifietl,packaged, <br /> p x' <br /> marked and labeled/placarded,and are In all respects in proper condition for transport according to applicable mtemationaland national govemmental regulations,If export shipment and I am the Primary <br /> Exporter,I cenify that the contents of this consignment conform to the terms of the attached EPAAcknowletlgment of Cans t. <br /> I certify that the waste minimization statement identified in 40 CFR 282.27(a)(d I araa large quantity generator)or of(Ifl earn Generator's fferor's PrintedRyp Names quantitygenerataidis We. <br /> Signature <br /> Month Day Year <br /> ...r 1 . aG'ona Shipments `. 8 q <br /> ❑Import to U.S. ❑Export from U.S. I <br /> ? Transporter signature(for exports only} all of entryleziC <br /> Ca 17.Transporter Acknowledgment of Receipt of Materials Date leaving <br /> Ul <br /> K Transporter PrintedRyped N e <br /> a v Signature <br /> Month Day Year <br /> L <br /> Q der 2 Primed(Typed Name <br /> Signature <br /> F- I Month Day Year <br /> } 18.Discrepancy <br /> I 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> 18b.Alternate Facilily(or Generator) Manifest Reference Number <br /> J U.S.EPA ID Number <br /> U <br /> LL Facillty's Phone' <br /> Liu <br /> 18c.Signature of Alternate Facility(or Generator) <br /> Q <br /> z Month Day Year <br /> H19.HazardousWasteReport Management Method Codes h e.,cod a for hazardous waste treatment,dis)osal,and recycling systems) <br /> C3 1 / <br /> G 2. 3. <br /> 4 <br /> 20.Designated Facility, <br /> Pont d Name Owner or Operator:Certification of. ceirtt of hazardeus materials covered by the manifest except as noted in Item 18a <br /> Signa <br /> . ! Month .jyY Ye <br /> EPA orm 0-22(jtgv,12-11) previous editions are obsolete. �!/� l <br /> DESIGY TQ EPA's e-MANIFEST SYS EM <br />