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FISU Sys SHIP4 F246 67E! Hi ll11111loll 111 11 006461664 SKS Please print or type.(Form designed for use on elite(12-pitch)typewriter.) form Approved.OMB No.2050-0039 1.Generator ID Number 2.Pa 1 of 3 Emergency R nse Phone 4. n st rae�n Nu be UNIFORM HAZARDOUS €- a; + �l 4 C� SKS WASTE MANIFEST, 1— 07 �� V 11 S 5.GeneratorsName and MaAddress Mailing Address Generators Site (if d'dferent than mailing address) 1 Lift FT1 e 3&V Bina Way TMCY Gen rsPtrone: U.S.EPA ID Number INC U.S.EPA ID Number 7 TrApsparter2;CAmpary elite _ ;gig . . j Aj- Btic y Nldress CLEAN AR RS O' W I L INT N LLCus.EPA ID Number 17 ' FAST PENN! €' REEF WILMINGTON CA ' 744 f'AaI44429875 to gb '1�(5' tio�[urdtding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Tnfe1 12.Unit 13.vas Codes end(+�cJFlix�' PI'dY)) No. Type Quantity Wt-Nd. 3.- 4. 14.Special Han9gng lnstnrcHonsaM Additmnal Informations. , 214 HA EMERGENCY #I—SW-4168-1760 i CH / SKTF 1,, A�,o AS "AGENT—FUR" 13Y GEN TO RETAIN } § �` E 15. GENERATOR'S10fFEROR'S CERTIFICATION:1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, 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 Exporter,I certify that the contents of this consignment conform to the terms of the affad*d EPAAcknowledgment of Consent. 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. Genemtoesl0fferors linntedflyped Name Signature Month Day Year a (�U�✓ 31 --j 16.Intonational Shipments ❑Import to U.S. ❑Export from U.S. Pat of entrylexih Transporter signature(for exports only): Date leaving U.S.: s W 17.Transporter Acknowledgment of Receipt of Materials Transport,1 Pd ted NameSignature ) Mont Day Year 41 a T Year aTra Printed yped Name Signature t 69k /t /y 18.Discrepancy 18a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fug Rejection Manifest Reference Number: 18b.Ajtemate Facility(or Generator) U.S.EPA ID Number J_ ra facility$Phone: llic.Signature of Alfemate Faality(or Generator) Month Day Year Z�siWaste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) 2. 3. 4. o.Operaror.Certitrratlon of receipt of hazardous materials covered by the manifest except as rated in Item 18a Signature Month Day Yeer L�- �Gseditoasaieobsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)