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7 <br />- Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />1111111111111111111111111111111111111111 <br />0 0 6 5 a 0 8 0 1 5 KS <br />Form Approved. OMB No. 205MO39 <br />UNIFORM HAZARDOUS' <br />1. Generator ID Number 2. 1�cf <br />1 3. Emergency Response Phone <br />i',I <br />14. Manifest Tra kl",N",b,r <br />' <br />WASTE MANIFEST <br />I . I <br />0 06520801 SKS <br />S. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) <br />S-ETY Ki D, T t�-O. FF! Y---[ , 1 '-FEN 53YSIIIEK-�, TN'C' SAFT- _E0111 f`YSTI:,M�l 1 C <br />rj . <br />B6X -FINK SN -j, V Dy <br />Generator's Phone: <br />6. Transporter Name U.S. EPA ID Number <br />71 -Company <br />L 7 FE <br />V N 5; V S TF M T1 I NIC <br />7.-Transporlar 2 Company Name U.S. EPA ID Number <br />A rll)t�! 71 R S, E N 9 1 tlbl;114! H A L S� I) C. I t. IF" <br />8. Designated Facility Name and Site Address F: flNjf' U.S. FPA 10 Number <br />33 6 <br />J <br />pt . -bl !71 j R G-Zlf 0 i Z <br />Facility's Phone: I <br />9a. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10, Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt./Vol. <br />rR.;i3 �it 'D U' F* D Fl 1 1 1 <br />(e --}j1` 4 ' <br />P <br />2. <br />LU <br />3. <br />4. <br />t4 Special Handling Instructlons and Addltional Information <br />T ST) T PO <br />7 RIGIFINICY i -8C110—ii 9-- 1760 M11- SK I T' <br />Vii;01; to hl 1 1' -f -R fle D v - <br />tents of this cons by ll shipping name, and are classified, packaged, <br />1�1 GENER46kSIOFFEll C�RTIFICA70W- I 7�e�i6y d7cloa-re that the conc er-etlty an i�i turateiy described above <br />marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable il and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I car 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 I am a large quantity generator) or (bam a small quantity generator) is true, <br />G�6roes/Offiaraes Pr/Typed Name Signature M th D Year <br />016,lRte <br />F— <br />%ational <br />hipments <br />0 import to U.S. El Export from U.S. On Of Irylexil <br />Tra rorte <br />lure (for exports only): Dung U.S.: <br />LU <br />17. Transporter Acknowledgment of Receipt of Materials <br />a th Year <br />T �ar 1 PrInted/Typed. Signaturell' <br />T� �E- <br />. <br />Im <br />C, me Jg <br />4c, <br />Trahsporter Printed yped Na. Signature Month Day Year <br />18. Discrepancy <br />I Ra. Discrepancy indication Space 11 Quantity ❑F77ype E:1 Residue El Partial Rejection ❑Full Reledion <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />Zi <br />U- <br />Facility's Phone: <br />0 <br />LLI <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />0 <br />Fn <br />19. Hazardous Waste Report Management Method Codes (Le,, codes for hazardous waste treatment, disposal, and recycling systems) <br />Z <br />4 <br />20. Designated Facility, Owner or Operator, Certification of receipt of hazardous maledals covered by the manifest exce9O4 nctq6 in Item 8a <br />7,8, Signature mo& Day Year <br />A A� 1471 K <br />— <br />4. I I J01 <br />EPA Form 8700-22 (Rev. 3-051 Previous e0lons are obsolete. Ph -61 17V-rC) nt:qTlNATI()N �TATr- mr. PF0111FIll <br />