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Please odntortvr- 'Form de�ioned for use on efte (12 -Ditch) Woewriter.) <br />Form ADDroved. OMB No, 2050-0039 <br />UNIFORM HAZARDOUS <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GEKEPtI-7i INITIAL COP',.' <br />1. C-nt., ID Number <br />2, Pa I of <br />£�ncy Response Phone 14. <br />F.4,3 1 <br />it'L <br />Manifest Trackil <br />_M Number <br />002830739 SKS <br />WASTE MANIFEST <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />0 <br />Generator's Phone: -1 7f- <br />6, TransporterCo py Nam U.S. EPA ID Number <br />,t <br />7. Transporter 2 Company Nam UZ, EPA ID Number <br />B. Designated Facility Nam and Site AddressAPW Number <br />Us EMLOSY HNEU— <br />r'IDA <br />13 isE,- 9ITT-Y �V,,jf ?-cz <br />A L <br />F P. T <br />FaPh me: <br />cili <br />9a. <br />9b. U.S. DOT Description (including Proper Shipping Nam, Hazard Class, ID Number, <br />10. Containers <br />11, Total <br />12. Unit <br />HM <br />and Packing Group (d any)) <br />Quantity <br />AMML <br />13, Waste Codes <br />No. <br />Type <br />SOL N= <br />r <br />u 07 <br />Q <br />0 <br />CH RUM LN 1- FTIT 9 N.'-iW777 1 T T <br />2. <br />tL <br />CD <br />3. <br />4. <br />14 Special Handling Instructions and Additional Information <br />Sip <br />02 .t'Y;,Z-- <br />15. GENERATOR''CERTIFICATION: I hereby declare that the contents of this consignment are fully and acourately described above by the proper shipping name, and are classified, packaqW. <br />marked and labeledf*ciuded, 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 />ExponK I certify that the contents of this consignment conform to the tans of the attached EPAAcknowledgment of Consent <br />I oei* that the waste minknizatiDn statement identified in 40 CFR 26127(a) (9 1 am a large quantity generator) or (b) (41 am a small quantity generator) is true. - <br />GeneratorstOfermis PrinWyped Narni = Signature Month Day, Year <br />4 <br />ri <br />16. International Shipments <br />04porl to U.S. El Export from U.S. Port of enb)#O)dt <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Mater ads <br />Trangortef I Pfted/Typqd Name Signature Month Day Year <br />0Je <br />CL <br />co <br />Zransporter <br />2 PrintediTyped Name .r; Signature Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space El Quantity EITYPe ❑Residue Partial Rejection El Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Genwator) U.S. EPA ID Number <br />L<1 <br />Facility's Phone: <br />M <br />Lu <br />180. Signature of Alternate Facility (or Generator) <br />MWth Day Year <br />!;i <br />Z <br />0 <br />J519. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />1. <br />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 />I I I <br />PrintediTyped Name Signature Mont Day Year <br />I I I I I <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GEKEPtI-7i INITIAL COP',.' <br />