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-Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approyek-JS�K,14 2060-0039 <br /> 1.Generator ID Number 2.Page I of 3.Emergency Response Phone 14.M ifed Tracking Number <br /> UNIFORM HAZARDOUS f 21"it-2.Q)0 15'S:"` <br /> WASTE MANIFEST i_800-468-i 760 60 2151714. S S <br /> 5.Genersto's Name and Mating Address Generators She Address(d different than mailing address) <br /> Generators Phone: <br /> 6.��1.Comp Nam U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> 8.Designated Facility Name and Site Address SAFIETY-KLEIEN j' U.S.EPA ID Number <br /> CA 6 i 8 <br /> 1722 COOPER it--IRET'k RD111"i" <br /> DEXTTIK� TX <br /> FaciKVs Phone; <br /> 98, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WLAtol. <br /> i J <br /> 1R' t4A-3T'_ .BIL Q.0 IT !N.ci4 <br /> 0 1�iit rl 1 0.0E,N T fR 1 T L'L I`R.1 PE <br /> Z 2. <br /> LU <br /> 3. <br /> 4jN 4 <br /> 4. <br /> 14.Sixiblial Hftdirg Instructions and Additional I*rmation SK T F111"K#1 i i I I <br /> 15, GENERATOR'SlOFFERDRS 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 labeled1placarded,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 certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identIfted In 40 CFR 262.27(a)(d I am a large quantity generator)or(b)(If I am a small quantity generator)is true. <br /> Genetator's.101ferces Printeffyped Name Signature. Month Day Year <br /> _j 16.International Shipments <br /> ED Import to U.S. ❑awt from U.S. Port of entry/exit <br /> Transporter signatin(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Roo*of Materials <br /> Transporter I PMWI/Typed Name Signature Month Day Year <br /> az Transporter 2 PdnWrTYW Name y Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Faeft(or Generator) U.S.EPA ID Number <br /> :3 <br /> Family's Phone: <br /> LU <br /> Month Day Year <br /> Z I 8c.Signature of Alternate Facility(or Generator) <br /> a$C) <br /> 19.Hazardous Waste Report Management Method Codes(ie.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedlirryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />