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Please print or type.(Form designed for use on elite -pitch)typewriter.) Form Approved,OMB No,2050-0039 1.Generator IDN ber 2.P e 1 of 3.Emergency Response Phone 4.Manifest Tracking Number UNIFORM HAZARDOUS 9 9 Y 100 QT �, .,WASTE MANIFEST � � � � � � SKS 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phone: 6.Traps@orter.l 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.EPA ID Number Facility's Phone: ga, 9b.U,S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total,:: 12.Unit 13.Waste Codes HM and Packing Grovp(if any)) No. Type Quantity .. Wt.NOI, Z 2. t3 4. 14,Special Handling Instructions and Additional Information J 15. GENERATOR'S/OFFEROR'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 labelediptacarded,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 attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 GFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. GeneratoeslOfferoes Printed/Typed Name Signature Month Day Year. _J 16.IntemationatShipments u lv ❑Import to U.S. DExport from U.S. Port of entry/exit: Transporter signature(forexports only): Date leaving U.S.: 17.Tgr spoiler Ack!Y der rent of Receipt of Materials LLIEj Transpdrter l Printedi Typed Name _ Signature'. \ .y,! j� Mofith Day Yeer Q. ,♦. f t ;: ;�e �i:;a/ a 1 S< 4n..+` :•~__ �.r lr co ZZ Transporter 2 Pame -,..� Signature .-�� Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space Quantity Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator_ _ U.S.EPA ID Number _J uQ Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year 4 z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) co LU C3 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 18a PrirWyped Name t Srgnahre , r � Month Day y i fJi ) -n f' EPA Faint 6700 22,(Rev:'3 05} Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR