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SK SHIP# !1-1195,64811 Please print or types Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page,1 of 3.Emer ency Res onse Phone 4.Manifest Tracking Number WASTE MANIFEST 007180932 SKS 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) R 4 ne Rte CR 95304-9 109 Generator's Phone: U19-836-096 5 1 6.Trgyorter 1 CompL- N SYSTEMS I W U.S.EPA ID Number TX R 7.Transporter 2 Company Name U.S.EPA ID Number ENV SVC INC. €�lIII-22-51 8.Designated Facility Name and Site Address CLEAN HARBORS V I;�t14 �K NITA, SERV TCF Vii, IM U.S.EPA ID Number 2?47SHICWAY71 Facility's Phone: 308-235--4012 KIMBALL NE 691,45 D98172351, 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./Vol. 13.Waste Codes z 2. t 3. 4. - I a 14.Special Handling Instructions and Additional Information I)ERG# 1".7 1 a 24 R6NC #800-4F- --17 0--CFI/SK/TFI--Contr et retained by generator verfers, i,4 � r v i uthor y 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, 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 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)(if I am a small quantity generator)is true. Generator's/Offeror's Printed/Typed Name Signature Month Day Year ( a 16.International Shipments ❑import to U.S. Export from U.S. Port of entry/exit: m Z Transporter signature(for exports only): Date leaving U.S.: W 17,Transporter Acknowledgment of Receipt of MateriaUJ ls a 1-- � r � ,r Transporter 1 Printed/Typed Name Signature Month Day Year z Tansporter 2 Printed/Typed Name Signature Month Day Year Q [L' F 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantityyp j j ❑Type Residue Partial Rejection El Rejection Manifest Reference Number: 1Z 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ ra Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year a z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) C 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedlTypad Name Signature Month Day Year EPA Form 8700-22(Rev.12-17�Previous editions are obsolete. GENERATOR'S INITIAL COPY