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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Pagel I of IEmergency Response Phone 4.Manifest Tracki Number <br /> n <br /> IOUs <br /> UNIFORM HAZARDOUS 002 �6-7130 SKS <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> 1.7 <br /> 6 <br /> Generator's Phone: U.S.EPA ID Number <br /> 6.Transporter I Company Name <br /> 7.Transporter 2 Company—Name U.S.EPA ID Number <br /> a.Designated Facility Name and Site Address U.& Number <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 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity wt./Vol. <br /> l"Z11 Q <br /> 1. 44 -il-" f. <br /> 0 <br /> Z 2. <br /> LLl <br /> 0 <br /> 3. <br /> 4. <br /> -TT—Special�Handling Instructions and Additional Information 1 E, e. <br /> f <br /> 15. GEN r ERATOR'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 labeled1placarded,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 car*that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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. Month Day Year <br /> Generatoes/Offeroes Printed(Typed Name 51gqature <br /> IL <br /> K" <br /> 1q International ShipmentsEl import to U.S. El Export Port of entry!exit: <br /> Transporter signature(for exports only): "" I/ Date leaving U.S.: <br /> W <br /> 17.Transporter Acknowledgment of Receipt of Materials IV <br /> Month Day Year <br /> ppe­dNqDfEj Sighature <br /> TransportbrI, Printedi`T)t <br /> 0 <br /> 'Aj <br /> Signature Month Day Year <br /> Z Transporter 2 Printed/lyped me <br /> 18.Discrepancy Partial Reject on Full Rejection <br /> 18a.DiscrepancyIndication Space Residue F <br /> Quantity ❑�Ype <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facility's Phone: Month Day Year <br /> U0 18c.Signature of Alternate Facility(or Generator) <br /> 0 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recycling systems) <br /> CO) <br /> LU 2. 3. <br /> 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except aqp oted in Item 1 Be <br /> Fr5ptrfpyed NameSignature Month Day Year <br /> -N- <br /> -;�� DESIGNATED FACILITY TO GENERATOR <br /> EPA FoW87oO-22(Rev.3-05) Pre—Viomr6critioris are obsolete. <br />