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Please print or type.(Form designed for use 0n a its( 2-pitch)typewriter,) ,e . ;y 4) 2e '" 3 Form Approved.OMB No,2050.0039 <br /> UNIFORM HAZARDOUS j1-Gn'ratorIDN1mbo 2.Page 1 of 3.Emergency Response Phone 1 4,Manifest Tracking Number <br /> WASTE MANIFEST %�C�l.4�t?�Z1$ fhb mit+($ I 1 fft>�!�Jfa.1-�.� G1005929995 SKS <br /> 5,Generators Name and Mailing Address ( Generator's Site Address((f different than mailing address) <br /> I j,).f til j+1,) +-St�,D�ti t'+ a <br /> r <br /> '14 t''!`�I1 :1t.4 <br /> Generators Phone: <br /> 6.Transporter i Company Name U;S.EPA ID Number <br /> r <br /> 7.Transporter 2 Company Name U.S,EPA ID Number <br /> 8.Designated Facility Name and Site AddressU;B.EPA ID Number <br /> 10y�21 B�;t�taY�IPSO �:()rarj <br /> X1101 ) JOSE, f al <br /> Fad81y'sPhone: ( 1y-iso/} <br /> ga. 9b.U.S.DOT Doscfiplwn(including Propershipong,Nam%Hazard Class,ID Number, 10,Containers 11.Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(if any)) No, Type Quantity <br /> 1 F(k w��.)3�-!"�)C,)id! Ir,.t,!�t•'ir1,1if.,.l:'!t�ft WI.N <br /> oI. <br /> {S Z Et3I'llk3l )@ <br /> 0 )P F . <br /> "'".tl : l <br /> c <br /> .r <br /> Z 2. <br /> w <br /> C9 <br /> 4 <br /> i <br /> 14.Special Handling Instructions and Additional 1nfo atipn <br /> r4<t ='i�SI I�f' 'h'6-Y a 1 -81pg '68-1760;760 MIK l `1£ D <br /> •r r: .ray r i , - r °• • s, r• , .,..., Y :-�� ,.ear. <br /> 1�.`"GE ERATOR'S10 R S E T FICA :1 era ydeclare Iha'the co t is lit l i? sign Cs'e g and ag&lrately das ribed aUove bJ tib p � s Aping name,and are classified,packaged, <br /> marked and labetedtplacarded,and are in all r�spoa a In proper condition for transport according to applicable international and nalfonal governmental regulations.if export shipment and i am the Primary <br /> Exporter,I cartily that the contents of this const nmenl conform to the forms of the attached EPAAoknowledgment of Consent. <br /> I certify that the waste minimization statement IJenified in 40 CFR 262,27(a)(If I am a large quantity generakyr)or(6)(III am a sm911quantity.generator)is true. <br /> f'General rsfOfferoes PrintedlTyped Nam { signature llTrith Day Year <br /> im Al <br /> J 16.International ShipmentsY ❑ ff <br /> Import to J.S..5.I ❑Export from U.S. Port bf:entryfexil: <br /> Transporter signature(for exports only):- Date leaving U.S.: <br /> 17,Transporter Acknowledgment of Receipt of Matedale <br /> Trans rie Printedffyped Namer' Signal,re" ,+,� /; Month Day Year <br /> 0 11 <br /> Q Transp'rfer 2 PdAtedrrypa Name _ Signature _ h onih Day Year <br /> 18,Discrepancy <br /> 18s.Discrepancy Indication Space Quan"ty El Type ❑Residue ❑Pardal ReJeotlon ❑Full Rejecticn <br /> Manifest Reference Number: <br /> i8b,Alternate Facility(or Generator) U;S.EPA ID Number <br /> J <br /> w Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Monlh. Day Year <br /> Z <br /> 19.Hazardous Waste Report Management Mothod C des(Ce„codes for hazardous waste treatment,disposal,and recycling systems) <br /> w 1 3. d. <br /> 20,Designated Facility Owner or Operator:Certification of ecelpt of hazardous materials covered by the manifest except as noted inllem i88 <br /> Primed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3.05) Previous editions de obsolete. GENERATOR'S INITIAL COPY <br /> I <br />