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- IIIIIIIIIillll�lllllllllllllllllll OG6513823SK5 Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 r *WORM HAZARDOUS 1.Generator ID Number 2.Page of 3 Emergency Response Phone 4.Manifest Tracking Number p �( WASTE MANIFEST 006 513 H Z 8 SKS 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) Generators Phone: - U.S.EPAID Number 6.Transporter t Company Name - U.S.EPAID Number 7.Transporter 2 Company Name 8.Designated Factldy Name and Site Address _ U.S.EPAID Number Facilis Phone: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12,Unit 13.Waste Codes HM and Packing Group(if any)) ryo, Type Quantity W1.1Vol. 2 2. 3. 4. 14.Special Handling Instructions and Additional Information 15. GENERATOR'S10FFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are(idly and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that Me waste minimization statement identified in 40 GFR 262.27(a)(If I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Gene torslof erors PrintedlTyped N Signature Month Day Year Iii In am.ional Shipments ❑Import to U.S. ❑Export from U.S. Port of entrylexih. zTransports rsignature(for exports only)i Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Tra r 1 PdnledlTy Name Signature 7 Month Day Year { /() Q�TmnsV�porteridlTyped a Signature .nth Day Year �� 3 �� r 16.Discrepancy 18a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: U.S.EPAID Number 1 Bb.Alternate Facility(or Generator) J_ V r4i Facility's Phone: Month Day Year W 18c.Signature of Alternate Facility(or Generator) a z y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,aril recycling systems) in f / 2. 3, 4. 20.Des ated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest ex pt oled in Item 18a Month Day Year P d N a Signa 1 EPA Form 8700-2(Rev.3-05)Previous edilionsare obsolete, D SI NATED FACILI'l V`tO 6EWINATION STATE(IF REQUIRED)