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Please print or type-(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 2,Page Response one 4.Manliest Tracking Number JUNIF6RM HAZARDOUS 1 1.Generator ID Number nse Ph r I of Emergency ..... SKS WASTE MANIFEST U U o c' 5.Generators Name and Maiiing Address Generators Site Address(d different thiailing address) E.:7..,-a`? Generator's Phone: 6,Transporter U.S.EPA ID Number — pa Name 7 Nf, 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number hIN40 4-3Fir'14 PITR L-T Facility's Phone: 92, 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 Group(if any)) No. Type Quantity WI.Nol. kl 1 D '04 ' 6, 0 Z 2. UJI 4 14.Special Handling Instructions and Additional Information 7 r 40, Mir —Ds"2 15. GENERATOR'SlOFFEROR'S CERTIFICAll"110M.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 labeled/placarded,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)ff I am a large quantity generator)or(b)(d I am a small quantity generator)is true. Generatoes/Offeroes Printedfryped Name Signature Month Day Year + -1 116.International Shipments 0 import to U.S, FlExport from U.S. Pon of antyt-& Transporter signature(for exports only); Date leaving U.S,: 17'Transporter Acknowledgment of Receipt of Materials Uj Transporter I Printed7yped Name Signature Month Day Year 0 Z Transporter 2 Printedffyped Name Signature Month Day Year 18.Discrepancy 18a,Discrepancy Indication Space Quantity ❑Type ❑Residue El Partial Rjection El Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number Lf Facility's Phone: OU 18c.Signature of Ademate Facility(or Generator) Month Day Year 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling system) Uj1. 2. 3. 4, 20.Designated Facility Owner or Operator;Certification of receipt of hazardous materials covered by the manifest except as noted in Item 189 Printedffyped Name Signature Month Dey Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. G NERATOR'S INITiAL CC�-"-