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_;�� IIIIIIIII IIIIIIIIIIIIilllllllllllll <br /> �Is0�J'63- 15d '�J-V 005106426SBN <br /> Please pent a pe(Form desi red for use on elite 02-pitch)typewriter.) O( r(Fylorrn Approved.OMB No 2050 0039 <br /> UNIFORM HAZARDOUS I Generator ID Number 2.Page 1 of 3.Emergency Reapdnse 4.0 0 Id.ing 6 4 2 6 SKS <br /> WASTE MANIFEST <br /> 5 GeneralWs Name and MaJmg Address Generators Site Address IJ differentthan mailing address) <br /> Generators Phone U.S.EPA ID Number <br /> 6 Transporter 1 Company Name <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> e.Designated Facility Name and Sit@ Address U S.EPA ID Number <br /> Facile sPhone: <br /> 9a 9b.U.S.DOT Description(ceding Proper Shipping Name.Hazard Class.ID Number, 10.Cont@�ners 11.Total12.Una 13 Wavle Codes <br /> HM end Pading Group(if any)) No. Type ouantiry Wt.Nol <br /> a <br /> z 2 <br /> W <br /> 3 <br /> 4 <br /> 14 Special Handling Instrudnns and Additional Information <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby dedw9 that a*contents Of tris mraignmeam are fully and desrnbed above by Me proper shipping name.and am detaftid,pttdaged, <br /> marked and labeled!p4carded,and are n II respects n proper condition for fmspon ucordin9 to applicable immab raborW governmental regW�ans.M export www em and 1 am tit@ Primary <br /> Exporter.I ceNfy that ore oontents of this corggrcnent cw*tm to the Derma d this etlacned EPA Acknowledgment d <br /> I certify that the waste mimm abon statemem identified n 40 CFR 26217(a)(e I am a large quenty generator)or(b) I I a vuen for)is true. Month yYw <br /> �/ <br /> ra1Ws'OReroes PmWyPed Nana SignaMe �O I 5 <br /> ti <br /> 16 mtemalwal Shipments ❑import fo U.S. ❑Export from U.S. Port of anby!exit .--- <br /> ? Date leaving US. <br /> Transporter signature(for exports only). <br /> . . <br /> C I7.Transporter AdtrvwAedgment of ReoaiM of Materials Day Y <br /> T er 1 PrinledfT meS'gm �l�q' <br /> O <br /> a <br /> 2 Transporter 2 Pnn 'Typed Name Signature m Day Year <br /> IX <br /> h <br /> }I 16.Discrepancy <br /> I 16e.Discrepancy Indication Space ❑ ❑Type ❑Residue ❑Parva ejecban ❑Ft•Rejection <br /> Manifest Rate--Number <br /> U.S.EPA ID Number <br /> 16b Allemate Facility(or Generator) <br /> J <br /> U <br /> sai FxJrtys Phone: klorsh Day ear <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> Q <br /> Z <br /> y19 Hazardous Waste Report Management Medved Codes(i.e.,codes for hazardous waste tvatmbnt,ditgaeel•and necydnB sYss me) <br /> G 1 �/ 2 3 d <br /> 20 Designated facility Owner Operator C;:�7��� <br /> ehmardest except as used n Item 18a n y Year <br /> ? Name <br /> EPA Form8700-22(Rev 3-05)Previous edil DESIGNATED F T ESTINATION STATE(IF REQUIRED) <br />