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-Missing Manifest: Inspection item 115 <br /> PleaSP.print or t {Farm designed for use on eine(12-pildt typewriter.) <br /> UNIFORM NAZARDOUs I•Generator ID Number Form Approved,OMB No.2050-0039 <br /> 2 Page 1 of 3.Emergar-y Response Phone 4.MaMfest Tracking umber <br /> WASTE MANIFEST <br /> 5 Generate%s Name and Mailing Address <br /> 4 � SKS <br /> 70 Generabls Sde Addresv(d different then malting addross) <br /> Generator's Pinorie. <br /> 6 Trarspoder 1 Company Name <br /> U.S.EPA ID Number <br /> 7 Traesporter 2 Company Name <br /> U.S.EPA ID Number <br /> 8.Desi naiad Facility Nama end Sita Addmss <br /> trim :.l sr d_ i,, U.S.EPA ID Number <br /> N r :i + '. f+t' <br /> l'9 DIE <br /> FaCit s Phona: <br /> DOT Description pncluding Proper Shipping Name,Hazard Class,ID Number, <br /> HM andPaddnngGroup(ifany!1 �.Contaner.a it Total 12.Unit <br /> t . e <br /> VoT <br /> . ype CkuanUty Wt.lVol. 13 Wast <br /> Codes <br /> + ;AI <br /> Q t ... t;.t ;f 1C..:L 1\-0 <br /> i . <br /> -.-- idfaz 1. <br /> zw <br /> W 2, <br /> 3. <br /> MAR 2 7 2015 <br /> 4 <br /> IJCQI-rW F)C.:,) <br /> 14 SpecalHandingIns <br /> Vuclionsa^dAt!tlltion»Un(ormation <br /> m � <br /> "t <br /> t ,r <br /> 15 GENE ani(la ejedFp RDR S CERTIFICATION:I Hereby declare that the contents ei this consignment aro t ly.and acaratey descdued above by the proper Shipp ng name,and are classified,packaged. <br /> market and IdbC7ad,'piacarded,and are m all respects in proper cordrhon for transport accord b a governmental <br /> Exporter,I certify that the contents of this Consignment conform b the tarns of the attached EPA Ackn�gmem of d natfonai overnmen,�regulations.It axport shipmentand I am the primary <br /> I certify that the waste minimization Sta(enrent Identified in 40 CFR 26227(a)Id I am a large quantity generator)or(b)lift am a small quantity generator)is true. <br /> Generalor's1OOtf0mrs Prided/Typed Name s gnatu e <br /> ( e``' MWOr Day Year <br /> 169 intematronal Sn pmeMs l r rl C-. „+ <br /> Z ❑Import N U.S. ❑t:xoori from U.S. Pori of eri(rylexit <br /> Tramrporer signature(for cxoorts only): _ <br /> LU <br /> 17.TransporterA,cknowtedgrnem of Receipt of Mtat6n;ils Date leaving U.S,: <br /> � Trans 1 PnrKedliypad me Signalur� <br /> n..... Month Day Year <br /> 4 hayrSporter 2 Prinied?y Name _ / � ,��� <br /> Signature With Day Year <br /> 18.Discrepancy <br /> 188.Discrepancy Ince»tion Space r❑ ;�1 Duanrty rpP Lt Re"ue ❑Partial Rejection <br /> ❑Full Rejection <br /> 18b.Aitemare Facility for Generatur) Manifest Reference Number: <br /> _j U.S.EPA fD Number <br /> U <br /> IFacility's Phona: <br /> W 18C.Signature of Altemata Farikly;or Gene+atw) <br /> 14— lAonth Day Year <br /> r19.Hazardous Waste Repon management Method Codes(i.e.,Owes for hazardous waste treatment,disposal,and racy."systems) <br /> C3 t 2. 3 <br /> 20.Designated Facility(Tamer or Operatcr:CW"tion of tempt of hazardous male;iais rxiversd by lha in <br /> arnfesl except as need in Item t8a <br /> rinIedTyoed Name <br /> Signature <br /> r, !h Day Year <br /> EPA Forrn 8700,22(Rev3-05 Prevrous editions are obsolete. <br /> 1.4.s t; DESIGNATED FACILITY TO GENERATOR <br />