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10 0 5 9 6 3 4 0 3 S K S <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Generator 10 Number2.Page,lof 3.Emergency Resporise an U <br /> WASTE MANIFEST 1005863403 SKS <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailingaddress) <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> rFF Y1_�Ff- �.Y.'JTFMS, T NC. Y <br /> 7 Transporter 2 Company Name U.S.EPA 0 Number <br /> 8.Designated Facility Name and Site Address ;FF! FE <br /> U.S.EPA ID Number <br /> 'XIY- M. N SY�-;l <br /> Facility's Phone: <br /> 9a 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11.Told 12.Unit <br /> HM and Packing Group(if any)) No Type Quantity WVVoi. 13 Waste Codes <br /> 0 <br /> I4�1- <br /> 3 <br /> 14.Special Handling instructions and Additional Information <br /> b t Cto -11 C41) <br /> 15 GENERATOR'SADFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fuily and accurately described above by tte by shipping name,and are classified,pacxagea <br /> Marked and ia',eied;plaCarded,and are in all respects in prom condition for transport according to applicable intem-anor-al and national governmental regulations 0 export snornent and I ar,line Pru r.a.,y <br /> Exporte,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the wase minimization statement Identified in 40 CFR 262.27(a)(if:am a large quantity generator of(b)(it I am a small quantity generator)is true <br /> Generatoesi0fteror's PrinfecliTyped Name Signature Month Day Year <br /> 104 1141 2 <br /> -J 16 international Shipments <br /> 1— 1:1 Import to U.S ❑Export from U.S. Pon of entryiexA: <br /> '3 Transporter signature(for exports only). Date leaving U.S.. <br /> LW 17.Transporter Acknowledgrrient of Receipt of Materials <br /> U <br /> � Transporter 1 P intedrryped Name Sign nature <br /> 0 STPX/e Qt)L-t A, J Month Day Year <br /> UJ L <br /> Transporter 2 PnnterLT erne 164 1 IAI 1 17 <br /> Signature Month Da Year <br /> 18 Discrepancy <br /> 18a.Discrepancy Indication Spam Qrtfty EJ Type El ReW. ❑Partial Rejection ❑Fuh Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA 10 Number <br /> u- Facility's Phone <br /> 0 1 <br /> LUSignature of Alternate Facility(or Generator) Year <br /> R <br /> X <br /> !'S2 Mont Day <br /> 19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment.disposal,and recycling systems) <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 D Year <br /> EPA liQ2= <br /> 0 ,,2� <br /> A <br /> Previous editions are obsolete. <br /> , <br /> (IF REQUIRED) <br />