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Please print or type.(Farm designed for use on elite(124tch)typewriter,) Forth Approved.OMB No,2050-0039 UNIFORM HAZARDOUS 1.Genefata aD Number 2.Page 1 of 3.Emergency Response Phone 4. [fast Tracking Number WASTE MANIFEST SKS S.Generators Name and Meiling Address Generator's Site Address(if different than mailing address) i� Generator's phone: 6.Transporter 1 Campari 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 Farillty's Phone: 98. 9b.U.S.DOT Description(including Proper Slipping Name,Hazard Class,ID Number, 10.Containers 11,TOW 12.Unit 1. HM and Packing Group(If any)) 13.Waste Codes No. Tye Quantity Wt.AlW. O Z 2. W L9 3. 4. 14 Special Handling lgshuclions airdAdditranal information 15. GENERATOR'S10FFEltMS CERTIFICATION: I hereby declare that the contents of Ihts consignment are fully and accurately described above by the propershlpping name,and are classified,packaged. marked and labeledlplecarded,and are in all respects In proper condifion for transport acoarding 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 terns of the attached F.PAAcknowledgmeni of Consent. I certify that the waste minimization statement Identified in 40 CFR 262.27(a)(if I am a large quanhlygenerator)or(b)(di am a small quantity generator)is". Genwatur's0flarors Printed/Typed Name Signature Ih ay Year i 16.intema8onal Shipments ❑Import to U.S. ❑Export from U.S. Pat of entryraxd. Transporter signature(far exports only): Date leaving U.S.: 17.TransporterAcknowledgment oiReceiptof Materials Transporter 1 Pdntadlfyped Name Signature� � Monate Day Year a rn Transporter 2Printedrr NameSignature Month Day Year GC 18.Discrepancy 1 Be,Discrepancy Indication Speee ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: � 18b.Alternate Facility(or Generator) U.S.EPA ID Number Fadlitys Phone: UJ 18c.Signature ofAltemate Fa hty(or Generator) Momh Day Year 9 N19.Hazardous Waste Report Management Method Godes(i.e.,cedes for hazardous waste treatment,disposal,and recycling systems) p 1. 2. 3. 4. 20.Designated Fasality Owner or Operator:Cerifitcation of receipt of hazardous materials covered by the manifest except as noted in Item 18a Paniedlryped Name Signature tem— Day Year EPA Form 11700-22(Rev.3.05) Previous editians are obsolete. DESIGNATED FACILITY TO GENERATOR