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II I II I I I Ill 1111111111111111111 felll 11 11 Please print or type,(Farm designed for use on elite(12-pitch)typewriter.) 0 0 6 1 3 6 Form App8 4 5 K S roved.OMB No.2050.0039 UNIFORM HAZARDOUS 1.Generaror ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST SKS 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) v E TV-I I BEV SYSTEMS, i.ItiL= ti13r.E Y"-KLEEN SV�:TE°Fw, IN, f)X 5r 5050 SPI-109 BLUP Generators Phone, SA!_I DR r'^ .Y, ,c n 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address - __;.; U.S.EPAID Number OF I:ALIFf '.h t.,830 SMITH d2VE. 510-795--440Qi KIEWARN Facility's Phone: 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, !D Cont"ners 11.Total 12.Unit HM and Packing Group(if ani93.Waste Cotle5 % Type Quantity Wt,Nol. 1, W p0� I`iq U 2. W 3. r 4. 14.Special Handling Instructions and Additional Information 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, marked and tabeledlplacarded,and are in all respects in proper condition for transport according 10 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 attached EPA Acknowledgment of Consent. I certi that the waste minimizabon statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(JI am a small quantity generator)is true, neretor's! amt Prin ped Namere Month Day Year 5 ignatuOS 16.Inten-Atiefial Shipments Ll Import to U.S. ❑Export from U.S. Pon of entrylexit: Transporter signature(for exports only) Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials rans er 1 Pri ed.' ed Name nature Month Day Year 0. 1/7-1 ash Q Transpo PriFlied a Name ignature Month bay Ye eliC H 18.Discrepancy 18a.Discrepancy Indication Space ❑Ouantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b,Alternate Facility(or Generator) US.EPA ID Number J U u4- Facilitys Phone Lu 18c.Signature of Altemate Facility(or Generator) Month Day Year a z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and r"ding systems) w1 r- O ' 1 ( 2 3. 4. 20.Designated Facility Owner or 0 tor:Certification of receipt of hazardous materials covered by the manifest except as ni in Item tea PdntedMina0ame Signature Month Day Year �\J C 11 a EPA Form 8700-22(Rev.3.05)Fir seditionsare obs DESI ATEDFACILITYTODESTINATIONSTATE(IFREQUIRED)