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11111111111111111111111111111 IN 1111111 0 0 5 8 6 3 3 7 7 S K S Please print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050.0039 1.Generator ID Number 2.Page I of 3 Emergency Response Phone 4.Manifest Tracking Number UNIFORM HAZARDOUS ,Lt ` 0 WASTE MANIFEST 05863377 SKS 5.Generators Name and Mailing AddreSS Generators Site Address(ff different than mailing address) Generators Phone 6 Transporter 7 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facikty Name and Site Address - U.S.EPA ID Number 4 0,IIA L1i 3[`.. Faciiity's Phone, ga gb.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if arry)) No. Type Quantity Wt.Nol. 1. ¢O GOO rye•l -,.. a z 2. W C7 3. 4. 14.Special Handling Instructions and Additional Information 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,ard are classified,packaged, marked and labeled/Placarded.and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.Ifexpon 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)(itI am a small quantity generator)is true. GeneratarslOfferors PrintedlTyped Name Signature Month Day Year ac Char 1 y 1oz 0(,1 17 16.International Shipments [= ❑Import to U.S. Export from U.S- Port of entrylexit: z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgmentof Receipt of Materials Transporter 1 Pm4 WrTyped Name Signa lu Month Day Year I.KFrJ -- 0'Z «P 17 Q spo r2PrintedffypedName Signatu Month Day Year K r 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 U Facility's Phone: 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) 0 1, 2. 3. 4. 20.Designated Fadlity Owner or Operator;Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form8700-22(Rev.3-05)Previous edi5onsare obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)