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0 0 7 2 7 5 8 0 6 S K S Please print or type . Form Approved . OMB No . 2050 - 0039 UNIFORM HAZARDOUS 1 . Generator ID Number - rh _ 2 . Page 1 of 3. Emergency Response Phone 14. Manifest Tracking Number SKS WASTE MANIFEST 007275806 S KS 5 . Generator' s Name and Mailing Address Generator's Site Address ( if different than mailing address) - Z30 "Af 10141 b - A 95 ,368 Generators Phone . co° inn 6 . Transporter I Company Name U . S . EPA ID Number 7 . Transporter 2 Company Name U .S . EPA ID Number B. Designated Facility Name and Site Address U . S, EPA ID Number CLACKAMAS , OR 97@1 .r - 896A rpl � _ 7z1p _ :. c, 16 Facility's Phone: 9a 9b. U .S . DOT Desorption (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12 , Un8 13 . Waste Codes HM and Packing Group ( if any ) ) No. Type Quantity Wt./Vol . i OL ID o a ._ D P3 E 'SIL FILTERS } 2CJ � 9 Z 2 . W Y7 3. 4 , 14 . Special Handling Instructions and Additional Information - 15 . GENERATOR ' SIOFFEROR ' S CERTIFICATION : I heredy declare that the contents of this consignment are fully and accurately described above by the proper shipping name , and are Uassified , packaged , marked and labeledlplacarded , 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Cement. 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 small quantity generator) is We . Genera s/Off, Pirmed/Typed N Sgnalu Month Day Year 3 - F 16 . int ationat Shipments ❑ Import N U . S. El Expert from .S . Port of entry/exit:? Transporter signature for exports onty) : Date leaving U .S . : W 17. Transporter Acknowledgment of Rec*t of Materials K Transixtiffer 1 Pri dRyped Name Signal Month Day Year aKAU Z y d Name sig Month Day year 3 b/ Ile) t18. Discrepancy lata. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Repolion Manifest Reference Number. 18b . Aftemale Facility (or Generator) U . S . EPA ID Number J V LL Facility 's Phone : W 18c . Signature of Alternate Facility for Generator) Month Cay Year a z H19. Hazardous Waste Report Management Method Codes (i .e. , codes for hazardous waste treatment, disposal , and recycling systems) 2. 3 . 20. Designated Facility Owner car Operator: Certification of receipt of hazardous materials severed by the manifest except as noted in Item l8a I Pnnted(ryped Name Signature Month Day Year 5 3 Zo EPA Form 8700- 22 ( Rev . 12 - 17) Previous editions are obsolete . DESIPNATED FACILITY TO EPA ' s e - MANIFEST SYSTEM