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Please ,tint or type.(Form desi nod for use on elite(12-pitch)typewriter.) Farm Approved.OMB No.2050-00 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number SKS WASTE MANIFEST L 5.Generator's Name and Mallin Address Generator's Site Address(e different than mailing address) Generator's Phone: B.Transporter 1 Company Name U.S.EPA IQ Number 7.Transporter 2 Company Name U.S,EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: ga, gb.U.S,DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12,Unit 13.Waste Codes HM and Packing Group(if any)) No, Type Quantity ',vt.Nol. Z Z. 3- 4 f 14.Speciai 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 labelediplacarded,and are in all respects in proper condition for transport according to applicable intemational 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 EPAAcknowledgment of Consent. 1 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 PrintediTyped Name Signature Month tray Year -1 16.international Shipments r—� zL'Import to U.S. Export from U.S. Port of entry/exit: Transporter signature(for exports only); Date leaving U-S.: W 17.Transporter Acknowledgment of Receipt of Materials OTransporter 1 Printed/Typed Name Signature Month Day Year IL to • Q Transporter 2 Printedfryped Name Signature Month Day Year J- 18,Discrepancy 18a.Discrepancy Indication Space 0 Quantity D Type Q Residue ❑Partial Rejection ❑Full Rejection Man;dest Reference Number; >- 18b.Alternate Facility(or Generator) U.S.EPA 1D Number J cac ity's Phone. 1 .—nnatUre of Altemate Facility(or Generator) Month Day Year 19.Hazardous Waste Retort Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) W (((C 1. 2. 3 4. ( 20.Designated Facility Owner or Operator,Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18o Printed/Typed Name Signature Month Day Year t 8700-22(Rev.3-05) Previous editions are obsolete.