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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Farm Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3-Emergency Response P7pne 4.Manlfeat Trac ing Number �( WASTE MANIFEST SKS 5.Generator's Name and Mailing Address Generatoes Site Address(it different than mailing address) Generator's Phone: 8.Transporter i 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,5.EPA ID Number Facility's Phone: ga, gb.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 1S.Waste Codes HM and Packing Group('d any)) No. Type Quantity Wt Nol. ve 1. Q � k 2. LU Ch — — 3. l 4. 14.Specal Handling Instructions and Additional Information 15. GENERATQR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and ate 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 oils consignment conform to the taroks of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 25227(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generato's/Offeror's PdntedlTyped Name Signature Month Day Year 16.Internallonal pments ❑import to U.S. ❑Export Tram U.S. Part of enlrylexit: Transporter signature(for experts only): Date leaving U.S.: L= 11.Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedlTypod Name Signature Month Day Year a a rn Q Transporter 2 PrintedlTyped Name sigrahkre Month Day Year a 18.Discrepancy 1 Be.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection ❑Futi Rejection Manifest Rathrence Number: t8b.Alternate Facility(or Generator) U.S.EPA 10 Number J_ V W Facilifys Phone: U, 18c.Signature of Alternate Facility or Generator) Mantlt Day Year a Z T 18.Hazardous Waste Report Management Method Codes{ix.,codes for hazardous waste treatment,disposal,and recycling systems) C 1. 2. 3. 4. 20.Daslgnaled Facifity Owner or Operator.Cartieation of receipt of hazardous materials covered by the manifest except as noted in Item 18a Print yped Name Signature Month Day ear EPA Form 87G0 22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR