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.......... <br /> Please print or type, 0 0 6 6 16 5 5 6 3 K S <br /> UNIFORM HAZARDOUS 1.Generator 10 Number �1�!1'7 2.Page;lof E-ei Phone Form Approved.OMB No.205M39 <br /> L. 41.Manifest Tracking Number <br /> WASTE MANIFEST . ....... 006686556 SKS <br /> 1.Generator's Name and Mailing Address <br /> Generators Site Address(if different than mailing address) <br /> T, <br /> Generators Phone: <br /> I.TT,i Iff f rr— <br /> r, <br /> S TNC U.S.EPA ID Number <br /> 7.Tran 2 CompanyiName U.S.I r-r-N," 1EPA ID Number <br /> 8.Designated Facility Name and Site Address ;JARBW! U.S.EPA 10 Number <br /> ,IPTI <br /> 11600 NORTH <br /> PRP04�ONJI TF T P <br /> Facility's Phone <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Parking Group(if any)) No. Type Quantity Wt./Vol, 13.Waste Codes <br /> Y 1. 1111N, cty ttt c T nMrP'M F D1111 Y',W11 <br /> 0 0R P <br /> hVr11 171, <br /> Z 2 <br /> UJI <br /> 3. <br /> 4. <br /> 14 Special Handling Instructions and Additional Information <br /> 7 A,!iti'0- <br /> 1)ERG-NH 33 -16 ue�,17� 0\0 <br /> rptaftne� by <br /> or,-initiill -anspor-ter, to j�dej [,I- SLtJ-j.t-, tk,, ddj t� -i a t- <br /> A tr C I i":xi',S I-J Gri t e. 1,T: q 0-0 A?r-ik t 0 <br /> 15. GENERATOFrS]OFFEROR'S CERTIFICATION: I hereby declare that the contents of this oonsignment are fully and accurately described above by the proper shipping name,and are ciassified,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 car*that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or I am a small quantity generator)is true. <br /> Generate fOlerces " ,, <br /> Printed d N S, to Month Dav Year <br /> c' )��/-�X Printed <br /> K4e a I` 1IFS, <br /> -J 16.International Shipments <br /> P- 1:1 Import to U.S. El Export from U.S. Port ofentry/exit: <br /> 9 Transporter signature(for exports only): Date leaving U.S <br /> X 17.Transporter Acknowledgment of Receipt of Materials <br /> L1J <br /> II-- Transporter 1 Printe(I/Typed Na <br /> W Signature Month Day Year <br /> 0 9�bfAJE— <br /> a- <br /> (n <br /> = lQwdporter 2 Pnnted[T g2OaW SignatuV <br /> < Month Day Year <br /> L-!�rzjo i3 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity D Type EJ Residue ElParlial Rejection ❑Full R.j.d. <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA 10 Number <br /> LL FacAtys Phone: <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 0 <br /> rt Ma <br /> po <br /> 19.Hazardous Waste Re <br /> I 2. 3,nagement Method Codes(i e.,codes for hazardous waste treatment,disposal,and recycling sys �tems� <br /> - <br /> O <br /> Hm T <br /> 4. <br /> 20.Designated Faciiity Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Hnnted/I yped NameHSig at e Month Day Year IGMAJ (Akl� d 2L&L I <br /> EPA Fwn.8 kev- 17�,Pfevious editions are obsolete. —111 —1 1 <br /> ; 1 . 1.1�,F I-- — Ll�DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />