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Please print or type,(Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No,2050-1 <br /> 1.Generator 10 Number 2.Ple I of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS 1.-, �rla <br /> WASTE MANIFEST SKS <br /> 5.Generators Name and Mailing Address Generator's Site Address different than mailing address) <br /> Paradise Poiri Marirtz <br /> 80,95 Rio Blanco Rd <br /> CIA <br /> Generators Phone: <br /> 6.Transporter I Company,Name U.S.EPA ID Number <br /> T <br /> - ; --- I ,yf.- <br /> --i i t-z.--�'i <br /> z 6 - <br /> 7.Transporter 2 Company Name6 ET 11)111�umb% <br /> yam; <br /> 8.Designated Facility Name and Site Address SAFET Y-KILSEN SYSTEMS, I NC.� U.S.EPA ID Number <br /> 6Z'00. 88TP STREET <br /> S-k <br /> CRAM E is'T Q CI4 9s"826 <br /> L3 <br /> Faciliys Phone: <br /> gai, 9b.U.S,DOT Description(Including Proper Shipping Name,Heard Class,ID Number, 10,Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WLN61. <br /> 1" . , o - <br /> 4- <br /> i..... ff i ON <br /> 2. <br /> CU i <br /> LU <br /> 3. 110Z 6 9 035 nn <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> M' C-4 --it-5akQ31,• PAIEJ-059 L-101749 SG.-23 <br /> &4 'HR '-1­0L-':,R6QN1CY # /0 ik <br /> 1, *�T, <br /> L- ��T AV GT�:N TTJ PF:Tk V Ir TnFNf;r-n !;1 FE raFgj; �4_ c,'�-: gn--d <br /> 15. GENEPATOR'SIOFFEROfVS 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, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and nabonal governmental regulations.If export shipment and I am the Primary <br /> - Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent <br /> 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. <br /> Gonertoft/OffeTes PrintedfTT rd Nae Signature1� Month Day Y" <br /> � <br /> 116.International Shipments <br /> F- Import to U.S. 7Export immus, Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> L O� 17,TransporbarAdmwledgment of Receipt of Materials, <br /> Ll <br /> 0 Trans? <br /> 0 "r I Printed"T"Ne,me Signature,, Month Day Ye. <br /> CL- <br /> Transportr2,Prmte ypodName Signature rS Month Day ye <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Spam <br /> Quantity Type M Residue El Partial Rejection F]NkRejection <br /> Manifest Reference Number: <br /> 118b.Altemate Fscillty�br Generator`' U.S.EPA ID Number <br /> Facility's Phone: <br /> Uj 18c.Signature of Alternate Facility(or Generator) Month Day Y( <br /> 2 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> U) <br /> UJ 1. 2, -7- <br /> 4. <br /> ?7.41 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest exceat as noted in item 18a <br /> Printed/Typed Name <br /> Signature 7 Month Day <br /> Ye <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete, <br /> DESIGNATED FACILITY TO GEN;= -F <br />