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Please print or type.(Foh designed for use on elite(12-pitch}typewriter.) Form Approved.OMB No.205HO39 1.Generator ID Number of 3 In,,,"R rise) 14,ManifestTradiiag Number ,'T HAZARD UNIFORM �JVS CAL,3 1012911'�'�.3'I' WASTE MANIFEST 006344620 SKS- S.Generator's Name and Mailing Address Generators Site Address(if different than am"address) r t a Rd Generator's Phone- 6.Transportar I Company Name w U.S.EPA ID Number 'S r. 7.Transporter 2 Company Name U.S.EPA 10 Number 8.Designated Facility Nam and Site Address t FSI.. U.S.EPA 10 Number 8ACR.114NEN DO a Facflftys Phone: 9a. go.U.S.DOT Description(Including Proper Shipping Nam,Hazard Class,ID Number; 10.Containers 11.Total 12.Unit 13,Waste Codes HIM and Packing Group(if any)) NO. Type Quantity WtjV01. �A- 0 IEOUS k" iRTS B 01 2. Uj 3. 4. 14.Special Handling Instructions and Additional Information C.r t 7- Fy fifhl P'F-TATS 15. GENERATORVOIFFEROWS 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 labelediplacarded,and are in all respects in proper condition for transport according to applicable international and national governments]regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the tens of the attached EPA Acknowiedgumt 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, GeneratoeslOfferor's NnWyped Name Signature Month Day Year F -j 1 16.Intetriational Shipments1.❑ I— Import to U.S, ❑Epi from U.S. Port of antryfwk Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintediTyped Name Signature Month Day Year rn0 CL M Transporter 2 PrinteNTyped Name Signature C I Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space FlQuantity L]Type F-1 Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number, U.S.EPA ID Number 4C Ll- Facility's Phone: In I Lu 18c.Signature of Alternate Facility(or Generator) Month Day Year 119.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling system) LU In 1. . ?.- � 3. 4, L r X Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in item 18a prinwiTyped Name Signature Month Day ear EFA'Form 8700-22(Rev.3-05) Previous editions are obsolete. J I ,�GENERATOR'S INITIAL COPY