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t ,v <br /> Please print or type,(Four designed for use on elite(1 pitch)typewriter.) FormApproved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone d.Manifest Tracking Number <br /> WASTE MANIFEST i? `r' . 's }:!' ,) {; E ?; 766 SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Generalor's Phone 1' a <br /> 6.Transporter 1 Company Name _TS.EPA ID Number <br /> .r rte tt,�.zi•.rC i•. ter. <br /> 7.Transporter 2 Company Name U,S;EPA ID Number <br /> B.Designated Facility Name and s ile Address U.S..EPAID Number <br /> �1.1.1 ,11 ti't <br /> 4{ <br /> Ilk <br /> Facility s Phone: <br /> 9a. 9b.U.S,DOT Description(including Proper Shipp ag Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(it any)) No. Type Quantity W1.1vol, <br /> Z 2, <br /> ILI } <br /> 3. <br /> 4, <br /> 14,Special Handling instructions and Additional Informsu n <br /> 01 <br /> 79 <br /> • i. 1.' r 1)i 35�f1t ' j! f�f'ril. �� f {L f'� j '1� f <br /> Ir 4 } ,.�, a -,. .r e4-♦ , <br /> 15. 'GEf1ER 4TOR SlOF ERO 'S CER IFICATf N: I atopy dtciar0 tYat'lftd c ntt—otic Cdnsi�itmanl a7 ully grid a curafeigGas'cribed abobn`by iRe pro a'shipping Hama;and are classified,packaged <br /> marked andlabeled/placarded,and are in all re8ped,in proper condifiomfor transport according to applicable international and national governmental regulations.if export shipment and I am the Primary <br /> Exporter,l cartify that the contents of this consignme it conform to the terms of the attached EPAAcknowledgment of Consent_ <br /> I cadifyOhat the waste minimization statement identied in 40 CFR 2612.27 (a)(it t am,a large quantity generator)or,(f)(ill am a small quantity generator)is trua. <br /> enerat r pt(oror'e Ped Name 7 })( Signatt4t ' Month Day Year <br /> 18.International Shipment9 <br /> � i ❑Import to ij.S. ❑Export.from UrS.t Port of entrylexik <br /> ? Transporter signature(for exports only): Dale leaving U.S <br /> 17.Transporter Acknowledgment ofRecoipt of Materials _ <br /> Transpo aft Printed pad Name $ignatuie Month Day <br /> Year <br /> , <br /> CL <br /> 1 <br /> Si n'ature `' Month Day ' Year <br /> Transpor er Print d ypad bme 9 <br /> i8.Discrepancy <br /> 18a,Discrepancy Indication Space Quantity Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Fadli (or Generator) U,S,EPA ID Number <br /> ty <br /> C3 � <br /> u. Facility's Phone: <br /> 18c,Signature ofAiternatefaci try(orGenerator) Mont Day Year <br /> u. <br /> 19.Hazardous Waste Report Management Method Code (i.e.,codes for hazardous waste Ueatmeht,disposal,and recycling sys(ems) <br /> A <br /> 20.Designated Facility owner ot-Operalor•CeAlAca(ion o receipt of hazardous materials covered by the manifest except as Hated In Item 188Month Day Year <br /> Pdnledjl`yped Name ignature <br /> GENERATOR'S INITIAL!COPY <br /> EPA Form 870022(Rev.3.05) Previous ed(gons ara o solata. r <br /> l <br />