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Please print or type.(Form designed for use on elite(12 pitch)typewriter.) <br /> UN M E•I�aZARDOUS 1.Generator ID Number Form Approved.OMB No.2050-0039 <br /> ( ( ft i7 • r. 2.Page 1 of 3:Emergency Response Phone, 4.Manifest Tracking Number <br /> TASTE MANIFEST r' `. r 1„ tF` tf <br /> 5.GeneratorsName and Mailing Address 15978861 SKS ] <br /> ¢ < Generators SiteAddress in different than mailing address) „V <br /> 59r t°tt t l 1 g �i t � Gat <br /> "� f )sk' :' �1� f Ftp �•:,€zi ( �� .. a c) <br /> Generator`s Phone. !P :'s—E�9 3Cf Fd f� � 13”17 rrsfe t v S <br /> am <br /> 6.Transporter 1 Compan 9708 <br /> Name tf° CA �� .s <br /> U.S.EPAID Number <br /> 7.Transporter 2 Company Name <br /> (1(; Iii (It; t f s t (st IL ETVIET..; �.�r(; U.S.EPAIDNum <br /> ber <br /> 8.Designated Facility Name and Site Address <br /> OF )R1J nNW 1 UL(!TJ U.S.EPAID Number <br /> Facilitys Phone: <br /> 136 CA 93aw <br /> 9a. <br /> 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, '/1'7)227�� <br /> HM and Packing Group(if any)) 10.Containers 11.Total 12 Unit <br /> No. Type Quantity Wt.Nol. 13•Waste Codes <br /> 1. NON ROAMODU-WAS TE 801 IDS f VI <br /> A 3 t 4 WASTE ��I C�a��C�� � E fit P <br /> AND f� t.) <br /> z, 2. <br /> w <br /> c� <br /> 3. <br /> 4: <br /> 14.Special Handling Instructions and—d—.... Information <br /> k ( ( R� 1�Y �ra 800-468-1760 (SK,J F'F" <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: i hereby declare that the contents of this consignment are fully and accureteiy described above b the"Yo i <br /> t� <br /> marked'and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental re ulafions. <br /> Y p per shipping name,and are classified,packaged, <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. If export shipment and i am the Primary <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator„or(ti)(if I am a small quantity�genera r)is true. <br /> Genertor's/Off ao"Ps"Frintedffype. Na/ne <br /> f''7� Sig�ttrre ,� �� , <br /> ' ( (` Month Day Year <br /> —+ 16.International Shipments <<, � <br /> H ❑Import to U.S. <br /> Z Transporter signature(for exports oni ❑Export from U.S. ,� Port of an <br /> y): <br /> W 17.TransporterAcknowiedgment of Receipt of Materials Date leaving U.S.: <br /> OTransporter)Printed/Typed Name ` <br /> Signator k <br /> 's �rri 11,3 7/14 <br /> Month Day Year <br /> Transpodar,2 Pdntedffyped Name <br /> < Signature <br /> 4� Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type <br /> 0 Residue ❑Partial Rejection <br /> ❑Full Rejection <br /> 18b:Alternate Facility(or Generator)'` Manifest Reference Number: <br /> J U.S.EPAID Number. <br /> J <br /> i Facility's Phone: <br /> Ai 18c:Signature of Altemate ility(or Generator) <br /> t <br /> z Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 20 Desi ated Facility Owner or Operator:Cerlification of receipt of hazardous materials covered by the manifest a cept as noted In Item 18a <br /> Fri y ed Name a <br /> � <br /> S, at r <br /> Month Day Y ar <br /> A Form 8700-22(Rev. -051 Previous editions are obsolete.' <br /> 1 _ DESI ATED FArI1 ITV T- <br />