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Pease prim or type.(Form de ' ned for use an eliteP 12 Itch typewriter.) 0 0 6 1 3 5 8 2 1 S K S <br /> ( ) Form Approved.OMB No.20"39 <br /> UNIFORM HI}2p RDOUS 1 fiEaeraEGr 1p Uun�gr 2.Page t of 3.Emergmry.,, Spmse pupae 4. nlfaslTrack+S Humtrer SKS WASTE MANIFEST 006136821 SKS <br /> GenerrattOt s Nr me and Mair g krusess Gaal nix's Sirs Address(if d fterant N1an rr>A address} <br /> Generator's Phone, <br /> 8.Trans�rter 1 EOmpany Name , <br /> J.S.EPA ID Number <br /> t,Trensperler 2 GOmgany Nares <br /> U.S.EPAiOtlumter <br /> S-QesV-1-a"gY Marne and Ste Adrtress <br /> U.S.EPA ID Numbw <br /> EacRitys PhDm: <br /> 9a 9b.Q3.DOT Dm*bon fir4uding Proper Shippjrrg Name,Hazard C3ass,i0 Nrraber, <br /> and P ) 16.L OrltalrrErE 11.Toldt 12,Ung <br /> HM 9 Grquts(tf any), No. Typo QLM RV MAIN. 13.Y#aste Cedes <br /> t. <br /> 2. <br /> w <br /> t <br /> s <br /> t <br /> 4,Specia H#aadiiag Instrtr awns and Ac notal Intormaua r <br /> TFTI <br /> 15. GENMTORII FEROR'S CERTIFICATION:I I>er*eedare dal hie mateM of thrs o3nslgnn�nt are fid and accurately described above 6 the sh <br /> modlad and W)e ecilplacarded,and aro in aH respects in pmt sr c_Aib_for y ° � ' are el&%liied.part'caged, <br /> ransport aecadrsg t aftpt Ga6ta intemaWnaiand national gm mmentat mg4aabons.If export sh prem,and I am ft Primary <br /> EYfb W t certify that the contents Uf d is mnsig marl W*nn t0 tirs temrs of the 3MUled FPA;ACkwMedgtnen(of Consent, <br /> certify lint ftwaste mit m zap statement idem tiad in d0 GFR Z62.27(a}{if 3 am a quarr;rty genwalor)or(b){di am a amap qua'*9—W)is true. <br /> Genera&sr'0fr0rexsPrint ypedName Siglaiuca MOt ❑ay Year <br /> ..! 1v.lnterrsatiocal W^nts <br /> ❑Import to U.S. ❑Export frau U.S. Port Of an te>trC_- <br /> TranSir signature(for expiurs a yi <br /> Date leaving U.S.: <br /> r <br /> .T.Transperter�:0 Rao*of k tenais <br /> Tr .s ?Pr rpt! Nam <br /> � }r "'yYear <br /> z �'` � <br /> 4Tmn4 aced`yped Nwe b Day Yearasy <br /> l8a Discrepancy Indication Space <br /> ❑4uaniiry ❑Type ❑Residue ❑Partial Resection ❑FuC Re ec8an <br /> Manifest Reference Number. <br /> 16b.Altemaks fac�ityr(rxGei>�ator) U.S.EPA 3Ct Nurrtbor <br /> s�i. FasKaysPfsona: <br /> lk 3±gnawreolimampteFa>ntiSyy(aGeneratari Month pay Yea <br /> 19.HazaWaus aVaste Reprat lozogemealt Methal Codas{I,s.,codas tar ha_0rd=wasta lmamwk disposal,aid mcyr ng systems) <br /> Ci 1 2. l <br /> a, <br /> les;naffed FacW Owner w Operator: QW*n 01 recai%Of haza da"raalsrials covered by the manligst axoept as raed in Item 18a <br /> P aNt S a Day Yaw <br /> EPA Farm 870Ct-2 { v. ) rs editinnsare fete. DESi Et ;1 iT Y TO l3STIAtA31Ol STATEOF REQUIRED) <br />