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_ 7. _ Illlllllllllllllilllilllllllllll�llli 0 0 5 9 4 7 2 3 6 S K S Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2054-0038 UNIFORM HAZARDOUS 1.Generator ID Number _ 2.Pace 1 of 3.Emergency Response Phone. 4.Manifest Tracking Number SKS c WASTE MANIFEST 0 V KS 5.Generator's Name and Mailing Address_ Gereraioes Siie Address(if different than mailing address) Generatcds Phone: 6.Transporter-t Cargpany.Name _ _ U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 9.Designated Facility Name and Site Address "- U.S.EPA ID Number Farilltv's Phone: ga. 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)) 13.Waste Codes No, Type Quantity Wt.Nal. - of O - w Z 7 f J, \ I t4.Special Handling Irnstruclions and Additional information 0 60 15. GENERATOR'SIDFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignmart are fully and accurately described above by the proper shipping name,and are classified.packaged, marked and labeledlplacarded.and are in all respects in proper condhion for transport according to applicable international and national govemmentsi regulations.If export shipment and I am the Primary E%Aortef.I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement idenEf&d in 40 CFR 262.27(a)(if I am a large quantity generator)or(b) a small quantity generator)is true. Ge 9tor'sl0fferor's tedfTyped Name Signature tlanth Day Year 16.Intemati I Shipments a ❑Import to U.S. ❑Export from U.S. Pprt entry xii: Transporter signature ffor exports only): Data le U.S.: Lx 17 TransporterAcknowledgmert of Receipt of Materials Tra s er 1 Prinlecirryp erne Signatu . Month Dav Year Z Transporter Print r a Signature Month Day Year elf 18.Discrepancy 18a.Discrepancy Indication Space ❑ Ouantiry El Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Facility's Phone, w 18c.Signature of AI!emate Facility(or Generator) Month Day Year a s Crn 7 19 Hazardous Waste Report Management Klethod Codes(i.e..codes for hazardous waste Imatmenl,disposal,and recycling systems) LLJ 14. 20.�Designsterrypedcl�Facllity Owner or Olor.Certification of reoaipl of hazardous materials covered by the manifest except as noted in Item 18a PrintedName �'�� - Signature h1ont' oav_ Ysar Z EPA For7n879Q22(Rev-.305.) Previous editions areodsokete. DESIGNATED FACILITYT D INATION STATE(IF REQUIRED)