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<br /> Please pian(or type.(Form designed for use on elite(12-pitch)typewriter,) Form Approved.OMB No,2050-0039
<br /> UNIFORM HAZARDOUS 1.Generator ID Number 2,Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number
<br /> WASTE MAN ( kUOiO-4.4. S -:Ii VAI � � '9�. � (�(�
<br /> 5.Generator's Name and Mailing Address Generators Site Address(if difierant than mailing address) *•� SKS
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<br /> Generator's Phone:
<br /> 6.Transporter 1 Company Name U,S,EPA ID Number
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<br /> 7,Transporter 2 Company Name U,S.EPA ID Number
<br /> f-1EAN eAV'dWAS EL 1tISNC13,XINIE-WIN ate(„ I Iff..
<br /> 8,Designated Facility Name and Site Address U.S.EPA ID Number
<br /> P1�WMtP FLUIDSSPV`C:
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<br /> Facility's Phone: r.,�a{ !1 r tb0 i7
<br /> ga, gb,U,S.DOT Descriptlon(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit
<br /> HM and Packing Group(if any)) 13.Waste Codes
<br /> No. Typo Quantity WLNoI,
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<br /> 14.Special Handling Instructions and Additional Information
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<br /> 16" 6 NERA DR'9l FE O 'SC IFIC N:1 ereby scare they the cbntente'Sft'ls ooneignment"are idly end accufelely esorl al abovaLyt eproper'shlpping name,aid are classified,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 thecontents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent,
<br /> I cedify that the waste minimization statement identified In 40 CFR 262.27ad(If I am a large quantity generator)or(b)(If I am a small quantity generator)is true,
<br /> Generator's/Offeror's Printed/Typed Name Signature Month Day Year
<br /> J 16,International Shipments
<br /> ❑Import to U.S, ❑Export from U,S. Pod of entrylexit: _
<br /> Z Transporter signature(for exports only): "' Date leaving U.S,:
<br /> w17,Transporter Acknowledgment of Receipt of Materials
<br /> OTransporters PrintedlTyped Name Signature Month Day Year
<br /> QTransporter 2 Printed/Typed Name Signature - Month Day Year
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<br /> 18.Discrepancy
<br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection
<br /> Manifest Reference Number: -
<br /> pY., 1Ble Alternate Facility(or Generator) U,S.EPA ID Number
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<br /> LL Facility's Phone:
<br /> w 18c,Signature of Alternate Facility(or Generator) Month Day Year
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<br /> y19,Hazardous Waste Report Management Method Codes(I e,codes for hazardous waste treatment,disposal,and recycling systems)
<br /> 1. 2. 8, 4
<br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a
<br /> PrintedlTyped Name Signature Month Day Year
<br /> PA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY
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