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Please PrIll orly'p;!form designed for use on -pitch)typewriter,) ForniApproved,OMB No.2050 003 <br /> UNIFORM HAZARDOUS I 1�Generator 10 Number TP,,ge I of 3.Emergency Response Phone an estTrykingNumber <br /> 11064 SKS <br /> WASTE MANIFEST 51 <br /> 5.Genera <br /> - fees Name and Mailing Address Goneralors SlIoAddiess(if different than mating address) <br /> I i, i'3' f1„e-a <br /> Generator's Phone: <br /> 6. nspor-lor I Company Name U,&EPA 10 Number <br /> 7 X R 0 0 0 0 12 0 <br /> 11,11VIV.—I"Y EMIS i";"I'Sit <br /> 7.Transporter 2 Company Name U,S.EPA ID Number <br /> 8.Designated Facility Name and Site AddressU.S,EPA ID Number <br /> UL'.AI's HARPICIR9 '91AN LIX <br /> I 1Ar"'RRY["�f3":A MAD <br /> "AN <br /> Facillys Phone: <br /> 93. 9b.U.S,DOT Description(including Proper Shipp g Name,Hazard Class,ID Number; 10.Containers 11,Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WLN01. <br /> I <br /> I f 1 61.1i 101 <br /> IS111AIXANE) <br /> 2. <br /> U.1 <br /> 3. <br /> 4, <br /> 14.'Special Handling Inslrucgons andAdditional Information <br /> r si. is T 6 'if 9 4 tJ1'J C 121 7 21 0 <br /> i~SilS�71r la' <br /> t'JChAEM(N 0 1.­Yj,*OI-4 *6­1760: ('SK if) <br /> 41 WI f._4'M 'riM 0r"T'(%T I <br /> and are classified,packaged, <br /> IRCAT-10q: ii�bby deolkolKif-thi _0 uaell� <br /> M <br /> 16. GENERATOR'S I'�',14,_-0jh,"o-offigh 6 A.y V'dR'ZTIftaboffivfiV'fi tr Upping name,a <br /> marked and labeled/placarded,and are In all respect In proper condition for transport according to appilcabi'a International and national governmental regulations.If export shipment and I am the Primary, <br /> Exporter,I certify that the contents of this cons4nmo it conform to the terms of the attached EPAkknowledgment of Consent. <br /> I artily that the waste minimization statement Identified In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(it I am a small quantity generator)Is true. <br /> '669tator'slo sroles PdntedfTypqd NrO Signature r Month Day Year <br /> =-To.—Inlerna o <br /> -pal Shipments <br /> Import to U.S. ❑Export from U,S, Pon Of entrY/6xll:' <br /> Transporter signature(for exports only); Date leaving U.S,: <br /> ct,Ttansporter Acknowledgment of Receipt of Materials <br /> Tri i=Pflnted[Typoa Name Signat6re, Month Day Par <br /> a. <br /> _Tr_an—sp_oKerg flidniddfryped Name Signature Month Day "I Ydi <br /> Ir—I <br /> 18.Discrepancy <br /> 188.Discrepancy Indication Space quantity t._! EIP,dial Rejection LJ F611 Rojectl::' <br /> Do. ❑ 0 <br /> Manifest Reference Number: <br /> 18b,Alternate Facility(or Generator) US,EPA ID Number <br /> zll Facility's Phone: Month Try' Year <br /> 18c,Signature of Alternate Facility(or Generator) <br /> ul <br /> 19,Hazardous Waste Report Management Method Code (i,e,,codes forhazardous waste treatment,dIs <br /> posal,and recycling systems) <br /> LU 1 12, T 4. <br /> 20,Designated Fadlily Owner or Operator:Codification ol receipt of hazardous materials covered by the manifest except as noted In Item 48a <br /> Month Day Year <br /> Signature <br /> PrintedlTyped Name <br /> EPA Form 8700-22(Rev.3.05) Previous aditlons'* GENERATOR'S INITIAL ICOPY <br /> �S <br />