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Please print or type.(Form designed tion use 06 elit,
<br /> 2-pitch)typewriter,)
<br /> UNIFORM HAZARD K (I tier Form Approved,OMB Noi 2050-0039
<br /> HAZARDOUS 2.Pagalof 3;Emergency Response Ph Manifest—Tracklng Numb 12050.0038
<br /> *1"
<br /> WASTE MANIFEST C'A L 0 q0401 I A-6 3 r-:1 01 �I;
<br /> 6.Generator's Name and Marling Address AM>283-39 SKS
<br /> I-,'it�41 c I) r I/ i�to;11
<br /> Generators Site Address(if—different than mailing address)
<br /> SKS
<br /> 214 1; t;t-t
<br /> C')'I'll f 0 1 r-,N TO
<br /> 9!J 8 t 6-- P 011
<br /> Generator's Phone:
<br /> Transrt
<br /> r I Company Name
<br /> I NG U.S.EPA—IDNumbe
<br /> 7.Transporter 2 Comp 'f x F o o o ti:
<br /> U.S.EPA ID Number
<br /> 8-Designate Facility Name and Site—Addtass +41RDURB BAN I 1118E L.IX U.S.EPA ID Nu 1—ber
<br /> nERRYFIF"Ji'A ROAD
<br /> -4 4 1 -096IA
<br /> 3j Facility's Phone: i V
<br /> 9a 9b.U.S.DOT Description(including Proper 8 lipping Name,Hazard'Cliss,10 Number,
<br /> HM and Packing Group(it any)) 10,Containers K Total 12,Unit
<br /> 1. 1 No, Typo Quantity Wt.Nol, 11 Waste Code I a
<br /> h1113 IRCRA R1,U-2 WARE 13'CIL106�
<br /> 0 1 D I'll F!a 3
<br /> N'e h
<br /> Z 2. •
<br /> 4,
<br /> 14,Special Handling In fluctions andAddillonal Inform tion,
<br /> X7 1 '13'Y G f A 7'-7 6 4 8 3 G.T.`8•3'7 q3
<br /> 24 HR #J-aq,
<br /> i68r-.1760 (11N
<br /> 15. GENERATORWOFFERCIR'S CERTIFICATI N:I hereby dedaraThal the contents of this consignment are fully and accurately described above by the properahlip
<br /> marked and faboleftlacarded,and are In all respe($in proper.oondig ping name,and are classified,packaged,
<br /> Exporter,I certify that ins Contents of this con On for transport according to applicable Internafforial and national govemmentalt"Viations.If export shipment and I am the Ptim
<br /> I ito ant lo.the terms.of the attached EPAAcknowledgmaht ofConsohl, sty
<br /> I certify that the waste minimizallon 6
<br /> lalemenlitden fied.in 4Q CFR 262;27{a}(ifl am a large quantityg@nerator}or(ti)(If Gama
<br /> leforslofferors Prinfe ypel:1 Name 6raI0r)lStfuq/"
<br /> j 16.International Shipments
<br /> i -1 import U.&
<br /> =.
<br /> r
<br /> Transporter signature(for exports only): nExpE.0thro U.S. Pod of antrylexit:
<br /> Uffi 17.TransporterAcknowledgment at Receipt of me-TaIS Data leaving U.S.;
<br /> Ifu[15PO 1 FrInle0118d Name
<br /> Slgnature�
<br /> 0 yp
<br /> IL Month Day Year
<br /> Z Transpo 6r, Me fryped ame
<br /> Signature 1knth Day Year
<br /> 18.Discrepancy
<br /> 188,Discrepancy Indlullon Space FI Quantity T* 0 Residue El 1"zirtill Re)s,ti, Dull Rjecdo'n
<br /> Manifos(Referen'd Number: i
<br /> 18b.Alternate Facility(Or Gen Generator)
<br /> ::3 DURPA-1 D-Number
<br /> L)
<br /> Fzldlity'.Phone:
<br /> IN,Olgnall.lfe OtAltettrale Facility(or Generator)
<br /> 1,la,'111,,or Go""'
<br /> C"'tam' I
<br /> Month Day Year
<br /> Z
<br /> Pod Me age
<br /> West.�Re Management Method Codes for hazardous We,(,
<br /> i9.Hazardous asta Report Management Method (to,,Codes for hazardous waste treatment;dlsposai,.and recydingsystems)
<br /> -20-.Designated Facilty Owner or Op,,atorr,CartfCation of a,'Ipt of hez,rdousm,j,dols,,ered
<br /> by 1
<br /> he manifest except as noed in IlanMeFnned'ryp,dNana
<br /> Signatu—re Month Day
<br /> EPA Form 8700-22(Rev.3-05)
<br /> Previous od-[1to—ns;--aT
<br /> aobsolete.
<br /> GENERATORIS INITIA/
<br />
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