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<br /> Please print or type.(Form dMigned for use on lite:12•pilch)typewfiter,): '' 4!,K' ;l ,ff ' Form Approved.OMB No,2050.0038
<br /> UNIFORM HAZARDOUS I.Generator ID Napier Z,Pago 1 of 3.Emergency Response Phone 4,Manifest Tracking Number (� �f SKS WASTE MANIFEST ' '1r iCStC.'1:�1 d +W'i! i 3. „t..tp,t j ;: 1 '`f'3 .��5 SKS
<br /> 5 Generator's Name and Mailing Address ( Generator's Site Address(if different than mailing address)
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<br /> Generatars Phone
<br /> 6.Transporter f Company Name t yt U:S.EPA ID Number
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<br /> 7.Transporter 2 Company Name i � U.S.EPA ID Number
<br /> C L EIRkI i'if'i't'ti'ADING G PIP I Pe IntIINU; IT OL QVC .(ilii.., I fif t,r��•~t/: y .:x'.r;.y
<br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number
<br /> Facility's Phone: 08'•44 1—rpt 3�'s�
<br /> ga, 9b,U.S,DOT Description(including Propf r Shi ping Name,Hazard Class,ID Number, 10.Containers 11.Tatar 12,Unit 13.Waste Codes
<br /> HM and Packing Group(if any)) No. Type Quantity XNOI,
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<br /> 14.Special Handling instructions and,Additional ini rmarn
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<br /> 15'."GENERA OR'S10 t?E t) 'S'G (FICA11 �!: 'iia dec dra at d is otlhldcoh�i nm kers' )i and adairaloly desdri6 a od by'lhe p o r;r"s i ping name,ard are classified,packaged,
<br /> marked and labeled/placarded,and are in all iespe is fn propercondillon for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary
<br /> Exporter,I certify that the contents of lhiscont ignmenl conform to the terms of the attached EPAAcknowledgmeni of Consent.
<br /> _.Lcertify that the.waste minimization statement ideal tied in 40 CFR 26227(a)(if I am a large quantity g$nerator)or(b)(if I am a small quantih enerator)i «re. _
<br /> general SJfW'is Printed/Typed Name; ( Sion td,reMonih Duly Year
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<br /> t_._I Import to U.S. ❑Export from U.S. Port QQf enttyfaxit,
<br /> Transportersignalure(for exports nly): I „Oatejq)avingU,S.;
<br /> UJ 17.Transporter Acknowledgment of Receipt of Mate als Y f I
<br /> Transpo rinlediTyped NameS(gna 0�re�� "'—� Month Day Year
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<br /> Transport Pnnta yped Name ' s'.,' .� SIg u Month Day Ye—
<br /> 18.D;cr pancy
<br /> 18a,Discrepancy Indication SpaceElQuan f
<br /> ty ❑Type 0 Residue ❑Partial Rejection ❑Full Rejection
<br /> Manifest Reference Number:
<br /> 18b.Allernato Facility(or Generator) U,S,EPA 10 Number
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<br /> ud Facility's Phone:
<br /> w 18c.Signature otAllemate Facility(or Generator) Month Day ! Year
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<br /> 'ala (Le.,codes for wasle.(reaiment,disposal,and recycling systems)
<br /> 65 19,Hazardous Waste eport Management Method
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<br /> Ll20.Designated FaciliNner or Operato'Certificallo. receipt of hazardous materials covered by the manifest excep gas no( In Item i8a
<br /> PrMled7Typad Name y r SignaturerA\\ 2C I
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<br /> EPA Form 8700-22(Rev.3.05) Previous dt ions . 0,solele. t✓ DESIGNATED FACIILITY TO GE ERATOFt
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