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Ptease print or type.(Form designed for use on elite(12-pitch)typewriter.) f=orm Approved.DMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Picone 4.Manifest Tracking Number WASTE MANIFEST SKS 5,Generator's Name and Maiiing Address Generalofs Site Address(if different than mailing address) Generator's Phone: S.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.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, 10.Ctmtainers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 1. cc O -- LU O 3. 4. i 14.Special Handling 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 labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcxnowledgment of Consent. I certify 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. GenoratVslOfferor's PdntedlTyped Name Signature Month Day Year J 16,International Shipments I-- ❑!.port to U.S. ElExport from U.S. Part of entrylexit: M Transporter signature(for exports only): Date leaving U.S.: LW 17.Transporter Ackno0edgment of Receipt of Materials tE Transporter 1 PrintedlTyped Name Signature Month Day Year O CL Z Transporter 2 PrinledfTyped Name Signature Month Day Year 1-- 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fuii Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U tE Facility's Phone: W 18c,Signature of Alternate Facility(or Generator) Month Day Year Q 2 F, 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) g 1. 2. 3. 4. 29.Designated Faciiity Owner or Operator:Certification of receipt of hazardous materials coveted by the manifest except as noted in Item-1Ba Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITYTO GENERATOR