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00572931 . t K s Please print or type (Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-00.'.0 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4,Manifest Tracking Number WASTE MANIFEST 005729315 SKS 5 Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name US-EPA IID�Number �,"n 1T D D ,3,-:?,9a 8.Designated FaciEity Name and Site Address U.S.EPA ID Number Facility's Phone: 91 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt.Nol 13.Waste Codes 1. .; ,,N'. ii% H r H4F�ifiiJt) I;9 }-�;5i[_,� I_i1�tjik,' o C`TIUEL1LIG PRRTE', WASHI=R f7,lTONti z 2. L c� 3. 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,aryl are classified,packaged, 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 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 CFR 262,27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generate rOfferor's PrintedlTyped Name 5i nature Month Day Year X rem ��5�� l) J 16.International Shipments H ❑Import to U-5- ❑Export from U.S. Port of enirylexit: Transporter signature(for exports only), Date leaving U.S.: W 17-Transporter Acknowledgment of Receipt of Materials W Tra o r 1 Pnntedfryped a Signature , Mon yepr O (7 y/� �(�/� n `+� V V 0) ve— Q Transports rinle !Typed_Name S gnalure Month Day Year � .q !� f— 18.Discrepancy 18a,Discrepancy Indication Space ❑ Ouantity ❑Type ❑Residue ❑Padial Rejection Full Rejection Manifest Reference Number FF— 1 Bb,Alternate Facility(or Generator} US EPA ID Number J u LL Facility's Phone: Ll 1 Be.Signature of Alternate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 12. 3- 4 20 Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Ba Printed ed Name Signature Month Day Year 1 4S'C' r i E A Form 8700 22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)