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e' II��I�I'llll l�'I"I'IIII II I��I II I�III � 0046471365KS Please pr nt or type.(For designed for use on elite(12-Ditch)typewriter.) ' Form Approved,OMB No.2050.0039 In� 1.Generator ID Number _ 2.Pace 1 of 3..�^� Phgng v C ManNest Tracgn Number UNIFORM HAZAR OUS %�" t Rg'` "�' 0 0 4 713 6 SKS WASTE MANIF T I S.Generatoes Name d Wading Add resa Generators Site Address(if different than mailing address) Gener for s Phone: 6.irgf5pgtff_l�Gom nyNAm _ U.S.EPA ID Numher 7.Transporter 2 Comf my Name U.S.EPA ID Number 8.Designated Fac!Ny Jarm and Site Address ? - - -- _ U.S.EPA ID Number FwKys Phone: oa, 9b.U.S.DOT ption IinduCug Proper Shipping Name,Hazard Class,10 Number, 10.Contame s 11.Total 12,Und 13 Waste Codes Ht,1 and Packing I roup(if anyp No. Type Ouandty WWOI. Q I W � I 2 W 1 t V J. i ) 4. i 14.Special Handlino StNelione antl AdtlNoal Infoma - _ - :Gr 1 ?-. c 'Z_ i T [- -, alj, ..m� n ...._ r_nu✓ 15. GENERATORI OFFEROWS CERTIFICATION: Ihereby declare that the contents of this ansignmem am fully and acarateydescribed above by the proper shipping new,and are dassfied,packaged, masked and lap, edlplaarded,and are in all respects in preperandition for tram pod according to applicable international and national govemmental mgulabons.It export shipment and I am fire Primary ' Exporter,I cavill that Ore contents of Ws consignment conform to the tem5 of the attached EPAAckrwwledgment of Consent. I cerdfy that the iashe minimeation statement identified in 40 CFR 262.27(a)(d I an a large quantdy generator)a(b)(if I am a small quantity generator)Is true. G nerames10fferors rintedffyped Name Si lure Month Day Year IOU I--1 16.International Ship nor ❑Import to U.S. ❑Export from U.S. Pod of entrytexi z TmmWu signs (for exports only): Dare leaving U.S.: w17 TransporterAckno dedgmentof Receipt of Materials r— T, 1 Print ed a SignaWre Month Day Year Gtr:P � l �aLA GTransputer 2 Primedl typed Name Signature Month Day ear [C A 16 Discrepancy 18a.Discrepancy IM'afion Space ❑ Quantity ❑Type ❑Residue ❑Pafial Rejection El Rejection Pro e Nb.: r 18b.Ahamate Facitdy or Generator) U.S.EPA ID Number J V rot Fedimy'5 Phone: Ow 78— Signaare—of Al te ate F,ciliy for Geneadr) Month Day Year Q _ a 19.hebedous Nasle Report Management Method Codes(i.e.,codes for hamrdous waste tre !0 1 2 3. 4. 20.Cesignated FacB' Owner or Operator.CerAfiation of receipt of hazardous materials covered by the manifest except as noted in Item 18a I Pri-:e:'typed Nang Signature Month Day Year 1 Previous editions am obsolete, DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)