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1 <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 14.Manifest Tracking NumberSKS <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> aI ; r�ii'� Shop 111_. _Nl1 J@ f7ws <br /> it <br /> i_;t' 952,06 21f71+ <br /> 1,f.. <br /> Generator's Phone: 761---', <br /> 6 Transporter 1 Company Name, p15 I rI U.S.EPA ID Number 1 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> -I_FPi! HARBORS kNVIRI]hII+1I=NIAL- SVC :III 14AD039322250 <br /> 8.Designated Facility Name and Site Address CLEAN ISARB01`6 �MVjc;Y MO NI A.a N - - U.SEPA ID Number <br /> 3 MILES EII 7 1411-ES FORTH N$+Il:ttrL.:a 1 41•, 01 60 <br /> KNOt-LS (JT 84083 <br /> 43n-884--A915 !i'1 t'e'a' -301748 <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 /> HM and Packing Group(if any)) No. Type Quantity wf.Nol• 13.Waste Codes <br /> 4;ZA tDQLIS Wl DF P D �D6 D�Q7 pQ� <br /> O S ('t AD�IIUM, I<I�ROMI1IM)g '.it I'i;l i i J �. ._ <br /> (f tat <br /> Z <br /> Z 2. <br /> ua <br /> C7 <br /> 3. <br /> 4. <br /> 14,Special Handling Inslruclions and Additional Information -•r` c-f CP4- 1 1a90° <br /> 1)ERG##1 I 1 <br /> c'.4 I-IF; UIEi MNCY 41-800-4 68-1760 (SK ! TF I) <br /> `�t:%: a LTi;"tlh�I1�PIT <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 labeledlplacarded,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 q€fant tygeneralor)or(b)(if 1 am a small quantity generator)is true <br /> Generator'slQffg7or's PrintedJyped Name Signature - Month Day Year <br /> -r 16.International Shlpmenis <br /> ElImportto U.S- ❑Export from U.S. Pod of entrylexit <br /> Transporter signature(for exports only), Date leaving U.S.: <br /> 0.' 17.TmuspoderAcknowledgmentof Receipt.of Materials <br /> w <br /> E Transporter 1 PrintedlTypeJ Name Signature' fl Month Day Year <br /> IL <br /> ., ' <br /> Z Tran Pd ted7Typed Name <br /> _� �L,796 <br /> .,. ,. Signature._._ �� f�• Month- Day Year <br /> 18.D screpancy <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 /> V <br /> w Facility's Phone: <br /> LU 18c.Signature of Alternate FaciEi,yjorGenerator) Month Day Year <br /> a a-. <br /> Z <br /> 55 19.H zar ous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. J4. <br /> 1 <br /> 20.Posigi Facility or or Operator:Cautification of receipt of hazardous materials covered by the manififst except as ed ib Item 18a 71 <br /> Prin y d ame Sig re M t •Day `Yea <br /> O` 1 <br /> EPA Form 8700-22{Rev,3-05) Previous editions are obsolete. FDESIGNATED FACILITY TO'GENERXr0FI <br />