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Please print or type.(Form designed for use on elite 12-pit, ,ewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Genrator ID Num r 2.Page 1 of 3.Emergency Response Phone 4�nifest Tracking 1.Number <br /> WASTE MANIFEST <br /> SKS <br /> 5 Generators Name and Mailing Address Generator's Site Address(if different than mailin EDD <br /> Generator's Phone: 2009 <br /> 6.Transporter 1 Company Name <br /> MST/S �yFALT" , , <br /> 7.Transporter 2 Company Name U.S.EPA ID Numb <br /> 8.Designated Facility Name and Site A dress ,,:,: _ U.S.EPA ID Number <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(induling Proper Sh pping Name,Hazard Class,ID Number, 10.Containers 11 Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(ff any)) No. Type Quantity wt./Vol. <br /> lX <br /> 1 e, <br /> V <br /> 3. <br /> i <br /> 4. <br /> 6 <br /> 14.Special Handling Instructions and Ac ditional Inform iton <br /> 15. GENERATOR'S/OFFEROR'S CEF TIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the Droner shiooino name.arxt are classified nackaned <br /> rna:rac anu.aueieu;piacarueo,anu are in ail resp lcLbo proper conuitUon for transport according to applicable international and nanonai governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents if this consigni lent conform to the terms of the attached EPA Acknowledoment of Consent. <br /> I certify that the waste minimization statement idei tified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator's/Offei%s Printed/Typed Nam q Signature Month Day Year <br /> 16.Intemational Shipments <br /> Z Import to U. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17 Tmncnnrtor 4rknrnnA?dnrranfof Ro—„r+,.r nn..�...,..i.. <br /> oTransporter 1 Printed/Typed Name Signature- Month Day Year I <br /> 0- <br /> Transporter <br /> Transporter 2 Printed/Typed Name Signature Month Day Year <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type <br /> ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) I i c con In ni,.,.k— <br /> _i <br /> V <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Gei erator) Month Day Year <br /> Q <br /> z <br /> N19.Hazardous Waste Report Management Method Cod (i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLJ p 1. 2. T <br /> 4. <br /> 20.Designated Facility Owner or Operator:Certification f receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> ..i�adwie luu iidi uay ieo� <br /> EPA Form 8700-22(Rev.3-05) Previous editions are c bsolete. GENERATOR S INITIAL COPY <br />