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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARt"30U5 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST SKS <br /> 5.Gemratoes Name and Mailing Address Generator's Site Address(if different than mailing address} <br /> Generator's Phone: <br /> 6.Transporter I Cempany Name U,S.EPA ID Number <br /> 7"Transporter 2 Company Name U.S.EPA tD Number <br /> 8.Desfgnaled Facility Name and Site Address U.S.EPA ID Number <br /> Facility's Phore; <br /> 9a 9b.U.S.DDT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(If any)) <br /> No. Typo Quantity Wtfvol. <br /> 1. <br /> 40 <br /> a <br /> r� <br /> ur <br /> C9 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 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, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicaUe international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of[his consignment conform to the terms of the attached EPAAcknovdedgmenl of Consent. <br /> 1 cartity that the waste minimization statement identified 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'sfOfferor's Printedfryped Name Signature Month Day Year <br /> r 16.Intemational Shipments <br /> Z ❑Impost to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Dale ieaving U.S.: <br /> W 17.TrarsponerAcknowledgment ofRecetptofMaterials <br /> Transporter 1 PrinledlTyped Name Signature Month Day Year <br /> CL <br /> 'Z <br /> Transporter 2 PrmtedfTyped Name Signature Month Day Year <br /> F <br /> 18.Discrepancy <br /> 1 Ba.Discrepancy indication Space El <br /> Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Attemate Fadi ty for Generator) U.S.EPA ID Number <br /> rar Facility's Phone: <br /> W t8c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.hazardous Waste Report Management Method Codes("i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> © 1. 2. 3. 4. <br /> F <br /> nated Facikty Owner or Operator;Certifirz4 on of receipt of hazardous materials covered by the manifest except as nded in flem 1$a <br /> ped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previnus editions are obsolete. DESIGNATED FACILITYTO <br />