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e print ortype,(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 1.Generator ID Number 2 Pagelof 3.Emergency Response Phone 4 Manifest7mcking Number WASTE MANIFEST ~ } SKS 5 Generators Noma and MadlogAddress Generator's SiteAddress(if different than mailing address) t Generators Phoma..,. 6.Trunsponor 1 Company Name U.S.EPAID 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.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(ifairy)) flm Type Quantity WLN01. fG 1 I O . .,;.rs xr..i r _...�..v..._..�_.j......_� r u�3 2' 1 i ( a. I 4. .Special HanTlingi instructions andAddilional Information 15. GENERATQR'SIOFFEROR'S CERTIFICATION:I hereby declare mal 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 fur transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I artity that the coolants of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. - - - I certify that the waste minimization statement Identified in 40 CFR 262.27(a)(if l am a large quantity generator)or(b)(If 1 am a small quantity generator)is true. - Generator`slOAenirs Pdnlelffy)Ied Name Signature - Month Day Year .r 1n,ImsoMa anal 5-ipirems � - F— ❑Import to U.S. ❑Exportfrom LLS. Pod efantrylexd Transporter signature(for exporls on0l. Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials` Fe Transporter l Pdntedl yped Name Signature Month Day Year 0 Q1 ranapOnar2 Vented typed Name Signalum - - - Month Day Year - r18.Oiscreparicy� Ills.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number,. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U w Facility's Phone: F 180.Signature c Altemate Family,(or Generator) Month Day Year 1g.Hazardous Waste Report Management Method Codes(i.e.,odes for hazardous waste treatment,disposal,and recycling systems) 2 3 4. ( t 28,Designated Facllily Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item IBe Pdnledfrypetl Name Signature Month Day Year r EPA Form 8700.22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILITYTO GENERATOR