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SK r?1-1 P# 22@9f;4599 <br /> 0 0 5 7 2 9 2 1 6 S K S <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response one 4.Manifest TrackiinggNumber �/ <br /> WASTE MANIFEST 005729216 SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> -EPiS, I N <br /> PO BOX555 SALIDA BLVD <br /> Generators Phone: LQll1 SAL IDA CA 95368 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number f r <br /> 7.Transporter 2 Company Name C1 14'� U.SMu <br /> D mber <br /> 8.Designated Facility Name and Site AddreL ��;- U.S.EPAID Number <br /> k Ja Bt3TH T i;F + <br /> CA 95828 <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> 1. <br /> ITR16F4 44Qw <br /> LU <br /> 2. NQNA HAI.ARL)QUS k4A L_I QLI I D <br /> (AD't1LOUS FARTS WASHER soLUTION) <br /> 3. U07ARn <br /> 1 -1 <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSL?!SCA <br /> z-4t / I C,o(�c_��'��i 3] <br /> :4 )art L::IMERLIEN Y .#i--8rn�,-468-1760 (SK ; TFT) �O i ! ) � <br /> -2-n 77!1.�l r r rr.,}t•.. - <br /> 15. GENERATOR'S/OFFEROR'S 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 labeled/placarded,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)(I I am a large quantity generator)or(b)(if I a small quantity gen tor)is true. <br /> Ge rat rs/Offerors Pri /Typed NameSignature Month Day Year <br /> J 16.Intern tional hipments <br /> Z ❑Import to U.S. ❑Export from U.S. Po6e-Jn <br /> /exit: <br /> Transporter signature(for exports only): DaU.S.: <br /> LU 17.Transporter Acknowledgment of Receipt of Matedals <br /> T19orter 1 Printedff ed Name Sigp ture Month Day Year <br /> CL ;P1 <br /> QTransporter 2 P riledName Signature Month Day Year <br /> `J e✓43 el-� Z Z� <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El <br /> Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> C3 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. 1 � 4. <br /> 1 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> /Typed Name Si Month Day Year <br /> EPA Form 8700-22 v.3-05) Previous editions are obsolete. DESIGNA'C D FACILITY TQDE TINATIQN STATE(IF REQUIR D) <br /> ��� <br />