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Please print or type.(Forin designed for use on elite(12-pitch).itypewidler. _2/Z. Form Approved,OMB No.2950,0039 <br /> UNIFORM HAZARDOUS I.Generator IONumbirr1pagoiof 3.15margencyRasponsophone 4,Manifest Tracking Number <br /> 5.Ganeralor's Name and Mailing Address 5.8 2 2 <br /> WASTE MANIFEST 24.1 SKS <br /> 00heraloeS Sitefit6dress(II'diffkroollhan I letting address) <br /> tri '(3-1 IT 0 <br /> GonerAtoes Phone: <br /> 8.Transporter�iCompiny Unit <br /> EPAID Number <br /> 7 <br /> P.Tminspoder 2 Company Name U.S.EPA ID Number <br /> ""a <br /> r Company <br /> S..Designated Facilityrre <br /> N and SIloAddress 1, U.S.EPA 10 Numbe r <br /> 11r( «��.� �r 4 <br /> Facility's Phone: <br /> 9a.F9b.U.DOT Description(including Propel Ship Ing Name,Hazard Class,10 Number, 10.Containers 11I.-To a] 12.Unit <br /> a <br /> HM and Packing Group(it any)) No. Type Quantity Wljvo�. 13,Waste Codes <br /> U <br /> 10P.11 R f,Ri.l QA Z IWI TE -KX,,P) <br /> r) <br /> Y T. T-F S <br /> T_ <br /> IJj <br /> 3, <br /> 4. <br /> L <br /> 14.Special Handling InsIruc!f0nsand Additional Infd I rM <br /> T80 11PA C I'1-379.3 <br /> 8-1160 (SK TF1 <br /> 15. GENERATOR'S OiIFER WS 612JR—TINCAT110V r fa y.d6c ere 111611111 6 <br /> tm'2161'1�r ate.classifled,pati <br /> Ttddl� re-ows'lighwent <br /> marked and labelediplacarded,and are In all respa s In proper condition for transport according to applicable International and national governmental re citations.ii export .1 and I am the Primary, <br /> Exporter,I certify thal,the contents of this can mr,ht conform to.the(armi the alla*oed EPAAcknowledgmiol of Consent. <br /> I 9ofy that the waste minl0zallon slateri entl;ed li CFR 262.21(a)(if I am a large quantity generator)or(6)(Ifl am a small ri4amlitygenei true, <br /> Generali lOgeroPsrPrfnted/Typed ams Signature Month Day 1 70-87 <br /> F- <br /> 16.intomailonai Shipments <br /> Import to U.S. Pont of onvyliKir. <br /> r port from U.S' <br /> Transporter signature(for exports only); i <br /> Date leaving U:S.: <br /> 17,Transporter Acknowledgmento[Rece'iptof Mate4s <br /> W Transport dritedfTypi Iqai Sggnauura <br /> 0Month Day Year <br /> CL <br /> Trarispo&f2PIrnted-f-ryTed—Na��o* <br /> Signature Month ~Day Year <br /> III.Discrepancy <br /> 18a.Discrepancy Indication Spacequangfy ETTYpeOReskiue FlattlalRelsIclion 0 Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) <br /> U.S.EPA ID Number, <br /> u- Facility's Phone: <br /> 18c.Signature ofAllernato Facility(or Generator) Month Day <br /> LU <br /> Year <br /> Z <br /> 19.Hazardous Waste Report MBnAg6ri Method Cadesi Lri codes For hazardous waste treatment,disposal,and recycling systems) <br /> TO.Dii <br /> naiad Facility Own8rorOperstor.Cgrifficall no[eoeiptofhazardous malerials-covered by the manifest except as noted in Item 118a <br /> _Frin­iod7TypeG Name <br /> Signature Month Day Year <br /> , L I <br /> EPA Form 8700-22(Rev.3-05) Previous editions a e obolete. GENERATOR'S INITIAL COPY <br />