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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number �/ WASTE MANIFEST SKS 5.Generators Name and Mailing Address Generators Site Address if different than mailing address) to 95366-30: Generator's Phone: 9?c-555-1640 6.Transporter 1 Company Name U.S.EPA ID Number TFM 7.Transporter 2 Company Name U.S.EPA ID Number S.Designated Facility Name and Site Address U.S.EPA ID Number Bvl'fUNW1LLUW , N 33LOti CAD98O575276 661-762-52@0 Facllity's Phone: ga 911 U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No Type Quantity WLNoI. 1, J K QO K Z 2. W f7 3. 4. 14.Special Handling Instructions and Additional Information TSD:Fl. :4138:0 T."GBS: , .hr.�,.... .r_ q.- '-1 7r 1_r^.n• r'ar-.•- r^nr.-...menn "+n.- v (."'f f21^' qF i..... .A 0..h 0�.: 15. GENERATOR'SIOFFEROR'S CERTIFICATION: Ihereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and Iabeledipiamrded,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 middy that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I caddy that the waste minimization statement identified in 40 CFR 262.27(a)(d 1 am a large quamity generator)or(b)(if I am a small quantity generator)is We. Generato'srOfferors Printed/Typed Name Signature Month Day Year 76.Intemati Shipments 1:1 Import to U.S. ❑Export from U.S. Pod of entry/exit: r Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printedrryped Name Signature Month Day Year O 13- W Transporter 2 PnntedRyped Name Signature - - Month Day Year Q K H t18.Discrepancy 18a.Discrepancy Indication Space Elpuantlty ❑Type ❑Residue ElPadal Rejection ❑Full Rejection Manifest Reference Number. r 18b.A1temate Facility(or Generator) U.S.EPA ID Number J_ x.) LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q 2 w19.Hazardous Waste Report Management Method Codes(i e.,codes for hazardous waste treatment,disposal,and recycling systems) Wo 1 2 3. 4. 20.Designated Facility Omer or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Il Pnnted[Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR STATE (IF REQUIRED)