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006136765 SKS Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMS No.2050-0039 UNIFORM HAZARDOU5 1.Generator ID Number 2 Pa 1 of 3.Erne{gencya Response Phone 4.Manifest Tracking Number . ,- c C SKS WASTE MANIFEST 001367 6 6 5 V K V 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) _.m' Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: ga 9b.U.S.DOT Description{including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No, Type Quantity Wt.Nol. 13.Waste Codes o ) 2e0 Z 2. W 3. 4. 14.Special Handling Instructions and Additional Information -70 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately descnbed above by the proper shipping name,and are classified,Qac ged, 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify 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 generator)is true. GeneratorslOfferors Pnntedrfyped Name �y Signature Month Day Year IV r?JviP07 127 r 16.Intemabonal Shipments r� ❑Import to U.S. Export from U.S. Port of entrylexit: ? Transporter signature(for exports only). Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials CC Transporter 1 Printed/Typed Name Signatu Month Day Year o a t E , 0-? Z 8-117 a nsporter2Print Name Signature Month Day Year 75 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J V Facility's Phone: W18c.Signature of Alternate Facility(or Generator) Month Day Year a z An19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1 2. 3. 4, 20.Designated Facility Owner or ralor.Certification of receipt of hazardous materials covered by the manifest except V noted in I 1 Pdntedfry N Signature Q " Y 4 EPA Form 870"2(Rev.3--1 Peviouseditions ate obsolete. DESIGNATED AGILITYD DESTINATION STATE ( F REQUIRED)