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Please print cr type. <br /> UNIFORM HAZARDOUS I.GeneratorlDNumbeT Form Approved.OMB No.2050-0039 <br /> 2.Page-1 of 3..Emorgency Response Phone ­F4—Manifest Tracking Number <br /> WASTE MANIFEST <br /> SKS <br /> S.Generators Name and-MailingAddress Generators Site Address ling address) <br /> Generators Phonefi Transporter 1 Company Name� <br /> 7 <br /> U.S,EPA ID Number <br /> 7.Transporter 2 Company Name <br /> J,S.EPA ID Number <br /> S.Designated Facility Name and Site Address <br /> U.S.EPA ID Number <br /> AF <br /> Facility's Phone: rr <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,11)Number, IG Containers 11 Total 12.Unit 13 Waste Godes <br /> HM and Packing Group(if any)) <br /> No. Type— Quantity VVt.NQL <br /> 11 V'11"�: F. <br /> 12. <br /> LU <br /> r. <br /> 4. <br /> 14.Special Handling Instructions and Additional information <br /> k <br /> 7 <br /> 15. GENEIZATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignmerfare fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and iabeled/piacarded,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 identified in 40 CFR 262.27(a)(if J am a large quantity generator)or(b)Of I am 6 small quantity generator)is true. <br /> Generatur's/Pfferor's Pirni Name nat <br /> Sigure.. <br /> I . .., Month Day Year <br /> V International Shipments <br /> 16. <br /> El import to U.S. ❑Export from U.S, Port f entrylex.it: <br /> ® Transporter signature(for exports only): 11 <br /> Date leaving U.S.: <br /> CC 17.Transporter Acknowledgment of Receipt of MaterialsLU <br /> Transporter—1Pnnted[Typed Name <br /> M i I Signature <br /> 0 Month Day Year <br /> CL 4 <br /> Z Transporter 2 Prii1teci I yi Name <br /> Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy indicator Space <br /> Quantity Ll Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) <br /> U.S.EPA ID Number <br /> Facility's Phone: <br /> LU 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> !R <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i a,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1 <br /> 0 1 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Cortificalion of receipt of hazardous materials covered by the manifest except as noted In Item 18a <br /> Printed Typed Name <br /> Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. <br /> D",ERAF R�S !W"AL COPY <br /> G <br />