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0061366375 KS <br /> 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 Tracking Number SKS e <br /> WASTE MANIFEST 0 V K V <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Generator's Phone: IAL T.DIA <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S EPA ID Number <br /> 8.Designated Facility Name and Site Adoress U.S EPA ID Number <br /> If <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) <br /> No. Type Quantity Wt.Nol. <br /> O <br /> Q <br /> w _ <br /> Z z r�RD4' 1 D <br /> WAS <br /> � WASHE� ::UL 1 i: ?'a? / v <br /> 3. tCRt, 'fAZA D01lS WASTE l_IGIUID <br /> (l40UEOUS PART$ WASHER SKUT T(?W G <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> + HR EM RbEN#,v 41-600-468--1760 ( I'K 1 FF f) <br /> ''-!-LI Of-F-KIT-.rr)Pss ['r\r r, -11, rtit ,•r r"td"_ r-s.T. <br /> 15. GENERATOR'SIOFFEROR'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,I certify 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 l am a small quantity enerator)is true. <br /> 7tor'sfOfferors Prin yped Name Signature Month Day Year <br /> J 16.Inter tional S ipments <br /> ❑Import to U.S. El Export from U.S. ntrylexit: <br /> z Transporte ature(for exports only) Ddaving U.S.: <br /> W 17.Transporter Acknowled pent of Receipt of Materials <br /> s iter 1 Printed ped Name Signature Month Day Year <br /> a � l `7 <br /> Z Trahspoted/Typed Name Signature Month Day Year <br /> \ °l g' <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type <br /> ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> ti19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> I L f 00 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedlType Name Signature Mo 0th D y Year <br /> EPA For 0 2(Re .3 5) Previous editions are obsolete. DESIGNAT CILITY TO DESTINA N STATE(IF REQUIRED) <br /> �� Page 6 <br />