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0 0 6 1 3 6 5 2 1 8 K S <br /> Please print or type,(Foa n designed for use on elite(12•p@chl typewriter.) Form Approved,OMB No.2050.0035 <br /> ? "IFORM HAZARDOUS 1.Generator iD Numiaer c a. 2.Page 1 of 3.Emergency Response Phone A.Manifest Tracking Number j/ <br /> 1 WASTE MANIFEST ` 5i 1006136821 SKS <br /> Ganeratoes Name and Maioq Adores Generator's Site Address(if ditfsrent loan mailing address) <br /> Generators Phone: <br /> 6.Trow-ler f Company Name J.S.ENA ID Number <br /> 7,Transporter 2 Company Name U.S.EPA to Number <br /> wl <br /> 8.Designated facility Name and Site Address :F+ w U.S.EPR ID Number <br /> 'i <br /> ��: IFl�.TCI <br /> Faeiilly's Phone: <br /> ga. 9b.'J.S-DOT Description(including Proper Shipping Name,Hazard Gass,!D Nurr"er i{-Containers 11.Totat 12,Lmt 13-Waste Codes <br /> HM and Packing Group(dany}i <br /> No. Type Ouanfity WtNoi. <br /> t i <br /> of <br /> UJI <br /> C9 (41'. I f ill tik poC . ft SIT_tI t r+ moll <br /> E <br /> E <br /> E <br /> 4.Spec!a Handling ImsWcdans and Acdifional Information <br /> HQ FMER6F-NL� <br /> .fps• <br /> ,rte <br /> a GENERATOR'SfOFFEROR'5 CERTIFICATION: I hereby ceclare that the cordents of this cNI&titmewam fatly and acowateiy described above by the proper ship -N name,an�are dassfied.pnkaged, <br /> markad and Iabeled(plararded,and aro in at respects in proper condition for 7anWort accorditg to appiica*irdemat wal and national govwmerrtal regulations.If export sh pment and t am the Primary <br /> Exporter I certify that the mordants of th constgnrtert Conlon to the terms of the atached EPAAcknowledgmenl of Consent. <br /> I certify stat the waste miwmtzat in statement idantifiad;n 40 CFR 262.27(a)(i!I am.a large gwt)14 generator)or(b)(ff I am a smail quantity generator)is hm <br /> GeneraI&siOfter&s Pnnted)Typed Name Signature Month Day . Y <br /> e <br /> a <br /> r <br /> J 16.Intematiorai Shipments <br /> t� ❑Impart to U's. ❑Erper;I.U.S. Part of ent wexit _ .. <br /> Transporter signature(for experts only) Dale leaving U.S.: ---- — <br /> *?,7€ansportwAcknovdedgrwr of Aeo*A of Malenats <br /> Uj <br /> �; T, s art Pa ted Name Sgnature Month Day Y <br /> 4. <br /> Q Trans 2 Hied%�ypad Nar'e 5 gnamre k"—!h Day Year <br /> 16,Disrrepanci <br /> I Ila.Discrepancy Indication Space Ouamiry EIType ❑Residue C Pariiat Re;ecticn ❑F•rrt R sect. <br /> Manifest Reference Number: <br /> lab-Altercate Faakrj!Qr Generator) U.S.EPA ID Number <br /> car <br /> FAAi, S Phone' <br /> w 16c.Signatire&AherraleFac€itj(otGerteratw- Month Day Year <br /> a <br /> 19-Hazardo4s Waste Report Management Method CcdEs(t.e-codes for ha2ardcus+aask treatm ort,disposal:and recyetng systems) <br /> d t. 2. 3. 4. <br /> CEsidratc-d Factiry Ohnief or Operator:C,erttcaMrt of receipt of hazardous malenals covered by the manKsl excepi as nsiec in Item 180 <br /> P Typed l ane Si ^.atU r Month Day 'year <br /> EPA Form 8700-2 { v. -05} re 's editions areolete 5E51cA ED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />