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<br /> I` -ple �4 m or type.{Form designed for use on elite(12 pitch)typewrder) `
<br /> .2050-0039
<br /> UNIFORM HAZARDOUS 1,Generator ID Number ( �1i_�3a 01,r 613.'# 2.Page 1 of, 31 Err�argepcy geapo{rse�Phope a 14.MaWfestTracklngNurrJb6r SKS,WASTE MANIFEST
<br /> 5 Gee accts Name and Mail ng Address` Gener tots Si(eAddressr(tf diflteInt than Mailing address)
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<br /> Generator's Phone:
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<br /> 6.Tra s,lie- Co any a ¢., U.S.EPA ID Number
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<br /> 7.Transporter 2 Co pang Name U.S.EPA ID Number '
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<br /> 8.Designated Facility Name and Site Address 6AFETY—KLVEN SYSTEM-)i t 4'iG U.S.EPA ID Number
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<br /> Facilitys Phone: .,
<br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Vbste Codes
<br /> HM' and Packing Group(if any)) No. Type Quantity Wt.Nol.
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<br /> � ,#!,tl€!°i (3ft') '1Jr% �44raiz 81A.t.�t ,t'flh)
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<br /> 14.Special Handling Instructions and Additional Information '€"f3')), 13C sz 77t -,?t A tr's'
<br /> . 1t f14-800-468-1760 # if /00
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<br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATIONt thereby declare chat the contents of this consignment are fully and accurately descdb" above by the proper'shipping name,'and are classified,packaged,
<br /> marked and labeled/placarded,and are in all respects Inproper condition for transport according to applicable international and nationa ovemmental regulations.If export shipment and I am the Primary
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<br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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 sm quantity generator)is true.
<br /> Generator'sl0 s Pn.ntedrryped Name Signature Month Day Year
<br /> 16.Intefiatrohal Shipment
<br /> ❑Expoil 4rom U.S. ort +ntrylexlt
<br /> Transporter signat(ire(forexpor1s only): '. b.
<br /> .D' Ieavin9 U.S..
<br /> 17 T risporterAcknowtedg%Ant of ptofUJ
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<br /> TrapaporFer 1 Pnnte fryped Name Signature"` �� Monthg 'Day Year
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<br /> QTransporter;2 PrintedlT ed Name , Slgnatare s" Month Day, Year`
<br /> its.Discrepancy
<br /> 18a.Discrepancy Indication Space El Quantity. El Type ❑Residue Partial Rejection ❑Full Rejection
<br /> - Manifest Reference Number.
<br /> -18b;,Altemate.Faality(or Generatgr)
<br /> rte_., � U S EPA ID Number
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<br /> Facilitys Phone:
<br /> U, 18c.Signature of Alternate Facility(or Generator) Month` Day Y
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<br /> 0 19i Hazardous Waste Report Management Method Codes(Le„codes for hazardous waste treatment,disposal,and recycling systems) _ ,
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<br /> 20.D'esighated Facility Owner•orI 0perator`;Certifioafion'bIf,
<br /> receipt of hazardous materials covered by.the manifest except as'ndted in Item 18a
<br /> Printad ped Name Srgnatu Month, Day Year
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<br /> EPA Forrrl$70�22(t3ev.3 Q5):Previous editions are obs te. �p `' J ESIGNATED FACILITY TO GENERATOR
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