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0 0 6 3 9 1 2 5 2 S K S <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number2.Page 1 of 3.Emergency <br /> WASTE MANIFEST Response Phone 4.Manifest Trackin Number <br /> - 0063T1252 SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> t 340 <br /> Generators Phone: <br /> 6.Transporter/Company Harp , U.S.EPA ID Numbersys <br /> 7.Transporter 2 Company Name f U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address C FA <br /> U.S.EPA ID Number <br /> •lr 4 :.. <br /> •(ch,,1 <br /> SAIN <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. _ <br /> z 2. <br /> LU <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information +< <br /> t ..-�i.t'.. 'i! µper.. �7� .- ._1 r�,?.. f•(.1 f (3K � !.i" .� t , Run <br /> _ a � <br /> Ct iTL I!! r qR-Pf-...ry FIR" BY GEN TO RF-r ;i N I..1 CENSU St JS t. R <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully an�Cnsent.urately d bed above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable internal and n al governmental regulations.If export shipment and I am the Primary <br /> Exp er,I c fy that the contents of this consignment conform to the terms of the attached EPA Acknowledgment oI ce i that a waste minimization stat ment ide 'fled in 40 CFR 262.27(a)(if I m a large quantity generator)or( am a la quantity generatoo is true. <br /> Generatos Printed/Typed N Signature Month Day Year <br /> WI <br /> LLL I X I I � I/Cs <br /> 16.International m <br /> z ❑Import to U.S. ❑Export from U.S. P.Tt en /exit: <br /> Transporter signal a(for exports only): Dat ea g U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> O Trans rter 1 Printed/Typed Name Signature Month Day Year <br /> CL <br /> r /& <br /> QTr nsp er 2 Pr ted/7 ame Signature Month Day Year <br /> ZZ 1 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity ❑Type <br /> ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> Month Day Year <br /> F <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1� 2. <br /> 20.Designated Facility-Owner or Op ator: rt'cation of receipt of ha us materials covered by the manifest except as n d in Item 18a <br /> Printed a Signature Month t)3 yE <br /> EPA Form 8700-22(Rev:3-05) Previous editions are obsolete. NATED FACILITY TO DESTINATION STATE(IF R//EQUIIRED) <br />