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IIiIIIIIIiIIIIIINIIIIIIIIIIIIIIIIII <br /> Please print or type. 0 0 6 7 7 6 1 2 0 S K E <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number - 2.Page4 of 3 finerAggry Rgspogce Phow¢ 4.Man'rfesl Tracking Number <br /> WASTE MANIFEST 0 0 6 7 7 6 12 0 SKS <br /> 5.Generators Name and Mail Address _ Generatprs,5yi1RAGQrgsat(if diffis <br /> al in mall ad ess) <br /> T - _ t <br /> Generator's Phone: <br /> 6.Trmsporteri-Company,Nmfe U.S.EPA 0 Number -, -...., ... <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facility's Phone: <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(If any)) No. Type Quantity Wt.NoL 13.Waste Codes <br /> 1 _ - - <br /> K <br /> O <br /> our <br /> 3 <br /> 4. <br /> 14.Special Handling Instructions and Additional Information I <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified.packaged, <br /> marked and Iabeledtplacarded,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 cediy that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent.. <br /> loath that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quantity generator)or(b)(if I a X <br /> xsma euantity generator)is true. <br /> Generators/OH ors PrintedlTyped name Signature Month Day Year <br /> (-.4~ 1 1o7 10910 <br /> 16 International Shipments <br /> ❑lmportto U.S. ❑Export from U.S. Rort of entry/exit: <br /> ? Transpoder signature(for exports only) i qatileavirl <br /> M 17.Transporter Acknowledgment of Receipt of Materials <br /> ILL! <br /> Transporterl PnntedfTyped Nam Signature Month Day Year <br /> 07 1,,ct 1 / <br /> QZ Transporter Printed/Typed Name Signature Month Day Year <br /> a <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Typej j <br /> El Residue Partial Rejection Full Re ection <br /> Manifest Reference Number: <br /> 13b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Faci'ity's Phone'. <br /> out 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> S2 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> N <br /> our , <br /> 1 / 2. 3. 4. <br /> (/ V <br /> 20.Designated Fal Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Prmted(Typed Name / Signature MMoonth Day Year <br /> EPA Form 8700.22(Rev.ll Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />