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Form Approved.OMB No.2050-0039 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> TTP g 1 of 3.Emergency Response Phone 14.Manifest eking Number <br /> ` 1. 1 ".i:�.z <br /> UNIFORM HAZARDOUS 1.Generator ID Number -- !";'.�.� . <br /> �i 3376226 SKS <br /> WASTE MANIFEST L <br /> 5.Generators Name and Mailing Address Generator'sSite Address(If different than mailing address) <br /> .... ...... <br /> -71 i i <br /> Generators Phone: U.S. ID Number <br /> 6.Trans1. <br /> nsporter 1 Company Nam, <br /> PA ID Number <br /> 7.Transporter 2 company Name <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> i+q <br /> Facility's Phone: <br /> 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.containers 11.Total 12.Unit 13.Waste Codes <br /> 9a. Quantity Wt.Nol. <br /> HM and Packing Group(if any)) No. Type <br /> PT T K l <br /> IC F"-r 0 <br /> 0 <br /> 2. <br /> UJ <br /> 3. <br /> 4. <br /> 14.Spacial Handling Instructions and Additional Information <br /> 4 1 A. <br /> J <br /> -"k <br /> J, 3,i�i I <br /> Fr-tk,11-l", <br /> 15. GENERATOR'SIOFFEROWS 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 car*that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity <br /> ty generator)is true. Month Day- Year <br /> r,rator'slOfferoes I Printed(Typed Name Signature <br /> -T <br /> -J 16.rintemational Shipments ❑Export from U.S. Port of entrylexit <br /> P- i Ll import t-U.S. Date leaving U.S.: <br /> Transporter signature(for exports only): <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> LU Month Day Year <br /> Signature <br /> 0 <br /> (40 i§ff6ture Month Day Year <br /> :Z Transporter 2 Printedffyped Name <br /> 18.Discrepancy <br /> 16a.DiscrepancyIndication Space El ou-art I ity-1 El Tyipe El Re s.idue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number. <br /> U.S.EPA ID Number <br /> 18b.Alternate Facility(or Generator) <br /> 1< Facility's Phone: Month Day Year <br /> LO18c.Signature of Aftemate Facility(or Generator) <br /> Ll <br /> !a J <br /> CDZ waste treatment disposal,and recycling systems) <br /> 19.HazardousWaste Report Management Method Codes(i.e.,codes for hazardous w <br /> 4. <br /> LM 1 2. <br /> 20.Designated Facil Certification of receipt of hazardous materials covered by the manifest except as noted in Item 188 <br /> Signature Month Day Year <br /> PrIntedrryped N / <br /> 77/ LeAle-/ 10 <br /> EPA <br /> DESIGNATED FACILITY TO GENERATOR <br /> Form 8700-52(Re7 3tf) Previo, -6SItions are obsolete. <br />