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Please print or type.(f=orm designed for use on elite(12-pitch)typewriter.) Farm Approved.pNtB No.2050 0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4,Manifest Tracking.Number WASTE MANIFEST SKS 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) u n Generators Phone: 0.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA Number 0.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, to.Containers 11Total 12.Unit HM and Packing Group(ft any)) .No. Type Quantity W1.Nol. 13,Waste Codes 1. c1C i O I w w O 3. 1 s i i 4. I 14.Special dandling Instructions and Additional information 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable hiemalionaland national governmental regulations.If export shipment and I am the Primary Exporter,f certify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Consent. I certify that the waste minimization statement identified in 40 CFR 282,27(a)(if f am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator's/Offerors PrintedlTyped Name Signature Month Day Year 18.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entryhwit a Transporter signature(for exports only): (}ate tearing U.S.: lLW 17.TransporterAcknowledgmenl of Receipt of Materials Transporter 1 PdnteVyped Name Signature O Month Day Year M rn Q Transporter 2 Printed/Typed Name Signature Month Day Year F- 18.Discrepancy 18a,Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Ful!Rejection Manifest Reference Number: 1$b.Alternate Facility(or Generator) U.S.EPA 10 Number �.r U uQ. Facility's Phone: LO 18c.Signature of Allemate Facility(or Generator) Momdr Cay Year a V519.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LLJ O 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedlTyped Name Signature Month pay Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR