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OC6136919SKS Please print or type.(Form designed for use on elite(12-pitch)typewriier.) Form Approved.OMB No,2050-0039 1.Generator ID Number 2.P e 1 of 3.Emer ency Response Phone 4.Manifest Tracking Number SKS UNIFORM HAZARDOUS ' O V KS WASTE MANIFEST 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) Generators Phone: 6.Transporter,I Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA 10 Number 8.Designated Facility Name and Site Address U.S.EPA ID Number I 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 1. tr 5 77sV Z 2. LLJ 3. 4. 14.Special Handling Instructions and Additional Information 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fuily and accurately described above by the proper shipping name,and are classified,packaged, marked and labelediplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulationsdexport shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment 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)(til am a small quantity generator)is true. Generatoes/Offeroes PrintedfTyped Name Signature Month Day Year X zi � cZ � x r�Mt,..,1.G► b? 3 � r � .j16.International Shipments F 11 Import to U.S. Export from u. . Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: Ll 17.Transporter Acknowledgment of Receipt of Materisis Transporter 1 Printed typed Name Signature Month Day Year aV VL +J �'`'�- 07 3 I 17 Zrran 2 Printedlryped Name , ignature Month Day Year ancy pancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Facility's Phone: W 18c.Signature of Alternate Facility(of Generator) Month Day Year a z 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 4. 1'Ea- LU 3. Y�oA - 1 20. signal Facility mer or Operator: rbfical on of receipt of hazardous materials covered by the manifest ex i as noted i em 1 Day' dy PiX0022a(ReC-05) Signature EPAFo Pteviou itonsare obsolete, DES GNATED FACILITY TO DESTINATION STATE(IF REQ IRE