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Please print or type.(Form designed for use on elite 12-pitch)typewriter.) Form <br /> Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.ManBestTracking Number <br /> WASTE MANIFEST SKS <br /> 5.Generators Name and Mailing Address Generators Site Address(it aliment than mailing address) SKS <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Nwnber <br /> 7.Transporter Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Fadlltys Phone: <br /> 9a. 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM 1.and Packing Group(if any)) No. Type Qui YNNW. 13.ideate con <br /> K <br /> QO <br /> K <br /> Z 2. <br /> W <br /> (:J <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 15. GENERATOR'SIOFFEROR•SCERTIFICATION; I hereby declare that the contents of this consignment are fully and accurately described above by the prapersMpping name,and are derailed,packaged, <br /> marked and Ialldewplaearded,and are in all respects In Proper condition for transport according to applicable intemabonaland ns8onel governmental regulations.if export shipment and I am the Primary <br /> Exporter,I certify mat the contents of this consignment conform to the hums of 8w atlaMed EPAAckmMedgment of Consent <br /> I certify Mat the waste minimization statement Identified in 40 CFR 261(if I am a large grwntitygenerator)or(b)(ill am a small quantity generous)is true. <br /> 3xinuaWfN08amrs PdntedfTyped Name Signature Month Day Year <br /> -+ 16.International Shipments <br /> Z <br /> El Import 10 U.S. ❑awfmn U.S. mMM <br /> Transporter signature(fpr exports s only): <br /> Date leaving U.S.: <br /> 19 17.TrensppwrAckrimwedgnwnl ofRewlptWMason& <br /> Transporter 1 PdntoCyped Name <br /> Signature Month Day Year <br /> R <br /> m <br /> Tmnsporter2 Printecirryined Name Signature Moth Day Year <br /> K <br /> r- <br /> ♦ 18.Discrepancy <br /> 18a.DiscrepancyIndkatlon Spece ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Ful Rejection <br /> Menifesl Reference Number. <br /> 18b.AlternateFadtby(a Generator) U.S.EPA ID Number <br /> V <br /> u Fadlitys Phone: <br /> 18c Signature ofAllernote Fadlity for Generator) Montl1 Qay your <br /> to <br /> N19.Hazardous Waste Report Management McBrod Codes(i.e.,codes for hazardous seats heatment,disposal,and recycling systems) <br /> p 1. 2. 3. 4. <br /> 20.Designated Fadlity Owneror Opeatu:Codification of receipt of hazardous materials covered by the manifest except as noted in Item lea <br /> 1 Pdnhidrryped Name bgnause Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous aditlunsamobsolete. DESIGNATED FACILITY TO GENERATOR <br />