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Please print or lvoe.(Form desioned for use on elite (12 -pitch) tvnewriter.l Fnrm Annrnvari OMR Nn 90011-nn39 EPA Form 8700-22 (Rev. 3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4 Manifest Tracking Number WASTE MANIFEST SKS 5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) Generators Phone: 6. 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 i (. }"fj d F irf2E`fi1iG U.S. EPA ID Number F,t; 00N I Ff. I IT 840 Facility's Phone: ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Gass, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity Wl.Nol. I.L PI.J I z "r 2. ; ,,.; v'. ;i rte por 3.?�?fif}f3L S-E^fi3 it E<,.." f7t _.. 1J%. _.... _ . _ J1. -1 4. i.� TIt['- ( •. 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 labeled/placarded, 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 EPA Acknowledgment 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) (III am a small quantity generator) is true. Generators/Offerors PrintedlTyped Name Signature Month Day Year F- 16. International Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit Transporter signature (for exports only): Date leaving U.S.: w17. Transporter Acknowledgment of Receipt of Materials Transporter 1 PrinledfTyped Name Signature Month Day Year O 0- QM Transporter 2 PrintedfTyped Name Signature Month Day Year H 18. Discrepancy 18a. Discrepancy Indication Space ❑ quantity ❑ Type ❑ Residue Partial Rejectionj Full Rejection Manifest Reference Number: r 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U Facility's Phone: W 18c. Signature of Alternate Facility (or Generator) Month Day Year Q Z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) � 1. 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a ted/Typed Name Signature Month Day Year EPA Form 8700-22 (Rev. 3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY