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Please print or type. _ 0 0 7 d otUrotie?.C7M6 A.20500.039 9 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Paget cf 3.Emergency Rospopse Phone t 4.Manifest Tracking Number ee <br /> WASTE MANIFEST � • <br /> SKS <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> ?_ , :fie` <br /> `s Generators Phone: r <br /> S.Transpft1 CompapyN me U.S,EPA IDNumber <br /> 7.Transporter 2 Company Name U,S.EPA ID Number" <br /> C INC. MA <br /> 8.Designated Facility Name and Site Address T f U.S:EPA ID Number <br /> Facility's Phone: <br /> ga• 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12:Unit_ 13: � <br /> HM and Packing Group(it any)) No Type tNfNd,. <br /> �a <br /> 2 NON-RCRA HAZARDOUS WASTE, L � bm <br /> 0 (AIDURILI.S MARTS WASNFR SAt lIT <br /> U0 <br /> 3 AZAt2T}OUS L <br /> ,)RRTz ,NASf- <br /> a, <br /> 14.Special Handling Instructions and Additional Information <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment am fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeedlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.tt export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify thatthe waste minimization statement identified in 40 CFR262.27(a)(if I am a large quantity general"or(b)(if I am a small quantity generator)is true. <br /> Ge torsfOfierorsP' y nesMonth DayYear <br /> 16. a i is pp--77 <br /> 1 Import to U.S. Export from US. Part of e'ntrylexit: <br /> ? Transportersignatute(for exportsonly): Date leaving U.S.: <br /> OC 17.TranspaterAcknowledgment of Receipt of Materials <br /> rterl Pnntedtf "&gvfdre •, MonthDay' Year <br /> nsporter 2 Pdnted/iyped Name Signa 're Month Day Year <br /> Air 1. <br /> 18.Dime,panoy <br /> 18a.Discrepancy Indication Space Q Quante 1:1 Trp. ❑Residue 0 Partial Rejection iJ Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator] U.S.EPA ID Number <br /> J <br /> v <br /> FarA y's Phone: <br /> w 18c.Signature of Alternate facility(or Generator). Month Day Year <br /> d <br /> 9 19.HazardousWaste Report Management Method Codes(1.e„codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. I d2012 3. ,. 4. <br /> 20:Designated Facility Owner or Operator:Certification of receipt of hazardous materiels covered by the manifest except as ndwIn @em 18a <br /> erne Sig Montlt Day; Year <br /> I <br /> EPA form 70022 ev. -17) rerevsviouss saloons are obsole <br /> OE tGNATED FACILITY TO EPA's e•MANIFEST SYSTEM <br /> - o n <br />