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<br /> P'fease priAr type.(Form designed for use on elle(12-pitch).(ypewriter.) Form Approved,OMB No,2650-0039
<br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page lof 3,Emergency R66ponsophone. 14.Manifest Tracking Numbot
<br /> o 10,
<br /> WASTE MANIFEST ,C'� 447 SKS-
<br /> 5,Goneralor's Name and Mailing Address Generators Site Address((f different than mailing address)
<br /> c ri r -s e jif F, n
<br /> S"fl'INAMENTO
<br /> Generators Phone: 9
<br /> 6.Transporter i Company,Name U,S.EPA ID Number
<br /> 7.Transporter 2 Company Name U.S,EPA 10 Number
<br /> B.Designated Facility Name and Site AddressU.S.:EPA ID Number
<br /> QLL'-I'AN HARBOR'S BAN ME LLG
<br /> iqe� SERIVESSA Root.)
<br /> ls'04
<br /> WO-441-0962 r
<br /> Fecilily's Phone:
<br /> Da, 9b,U.S.DOT Description(including Proper Shipp ng Name,,Hazatcl Class,ID Number, 10.Containers 12,U�nit 13,Waste Codes
<br /> No, Type
<br /> HM and Packing Group(if any)) I _f"
<br /> Quantity WI.Nal,
<br /> 1, NONE,, NON Oif,'RA HAZARDOUS WASTE MIA
<br /> 2,
<br /> LU
<br /> 3.
<br /> C
<br /> 74-8geclal Handling Instructions andAdditional Informatio I
<br /> laolw 6926'1679 C,'-T u.:79 3
<br /> �C4 HN EMEK'13101("Y M.—NO 4 8-1,760 'M TF )
<br /> hrr--prip u my 1 r.('Nl, Til 14Wlltrt'•fktit(A i"OVRTV'Rq W.,
<br /> 15. GENERATOWSIOFFEROR'S CERTIFICATION)I it reby declare that the conlorttsof this 6onsignmentare fully and accurately described above by the proper shipping name,and are classified,
<br /> marked and labeled/placarded,and are In all respech In properaondillon for transport according to applicable.in(emallonal and national governmental regulations.If expel shipment and lamthaPrImaty
<br /> Exporter,I certify that the contents of this conslgpment conform to the terms of the attached EPA Acknowledgment of Consent,
<br /> (,certify that the waste minimization statement Idiprillfi(d In 40 CFR 26227(a)(it I am a large quantity generator)or(b)(if tam small quantity generator)Is true,
<br /> ftetlofferars Printed/Typed Namesignature Month Day Year
<br /> -j 16.International Shipments
<br /> R IP,d to U.S. EIE,P,,,t from u,s, N Part of enlrylexil:
<br /> Transporter signature(for exports only): Date leaving U.S;:
<br /> W 17,Transporter Acknowledgment of Receipt of Materials
<br /> Tramp We F1 P Month Day Year
<br /> anledrTyped Name
<br /> 0
<br /> 0-
<br /> 0
<br /> Z
<br /> -M6nth Day War�
<br /> Transporter2 Pdritedffyped Naffid Silirliatutb- -
<br /> <
<br /> 18,Discrepancy
<br /> 18a.Discrepancy Indication Space El Quantity' ElTyp El Residue F] ❑Past Rejection Full Rejection
<br /> Manifest Reference Number:
<br /> 18b.Alternate Facility(or Generator) U.S.EPA ID.Number
<br /> ti
<br /> u. Fadlitys Phone:
<br /> 0
<br /> LIJ 10c.Signature of Alternate Fa Tility(or—Gonarato,) Month Day year
<br /> 19.Hazardous Waste Report Management Method Co6s:(.e.,codes for hazardous waste treatment,disposal,and recycling systems)
<br /> 3. -4,
<br /> 20.Designated Facility Owner or Operator;Certification oft icelpt of hazardous motorists Covered by the manifest except as noted In Item 18a
<br /> Printed/Typed Name
<br /> SIgnaturo Month Day Year
<br /> Ll
<br /> EPA Form 870022(Rev,3.05) Previous editions are ob,,olete. GENERATOR'S INITIAL COPY
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