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SK SHIP# 226366405 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Page,1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> UNIFORM <br /> WASTE MAN HAZARDOUS <br /> t.:AL1 �iD►01bb l9flt 009391449 SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> San I Pak Im <br /> Po Box 1183 <br /> TRACY EA 95378--11h <br /> Generator's Phone: <br /> �'�'g-835-3104 <br /> s.Trn�ptxter! frlV SYSTEMS INC U.S.EPA ID Number TXR000u, <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> MAD0393 <br /> 8.Designated Facility Name and Site Address __ -,,y r•{5 Fr; i ,; U.S.EPA ID Number <br /> 11600 NORTH APTUS ROAD <br /> ARAGONITE UT 84029 <br /> 435-884-8100 UTD98155217` <br /> Facility's Phone: <br /> 9a 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt./Vol. <br /> 1 UN 1325 WASTE FLAMMABLE: SOLIDS <br /> 0 RGAN , ,0.S. , (ACETONE, TOMENE:- , <br /> 4. 11 <br /> PG11 <br /> z 2. <br /> L <br /> c� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information ("jjl;AG 776074822 SA23574 r CSG: <br /> 7'4W FMERr N�'Y#RQIR-46A-17F4t-C'N/C1�/TFI-("ontr��t ret-p ned nv generator confers anp/Cy ar-tthora <br /> std' <br /> 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, <br /> 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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment 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 /> Generator's/Offerors Printed/Typed Name Signature '�x - Month Day Year <br /> J 16.International Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Nar�✓-,/� �y Signature Month Day Year <br /> W. <br /> O <br /> a <br /> aTransporter 2 Printed(Typed Nam / SignaSwe M pay Yeaj <br /> rx <br /> r- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> LL Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q1 <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EP4 Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />