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Please print or type. 0 0 7 0 4 0 2 4 a 8 K 8 <br /> 1.Generator ID Number Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS _-ate+__+ 2.Page of 3.l:mer,� Re <br /> _ f � � sp1,�(_ sl�or�e p� 4.Manifest Tracking Number <br /> WASTE MANIFEST 4 �E'' I�� O O 7 O 4 O 2 d p SKS <br /> 5.Generators Name and Mailing Address Generators Slte Address(ff different than mailing address} <br /> Generators Phone: °f'-F-S4 ' ::i=' T <br /> 6.7r�ns�4tipriftPmRgypr <br /> l <br /> U.S.EPA ID Number r-{ <br /> 7.Transporter 2 Company Name <br /> f7! <br /> j 1e U.S.EPA IDNumber <br /> 8.Designated Facility Name and Ske Address -- _; n° r- <br /> ``- M' :r T t-1E,:, U.S.EPA ID Number <br /> :i -_ - -,fit,_ — _ -. ..�4ii-<-„I�{.-F • ,;C f11.3�, <br /> - •v. - -F' 'rt <br /> Fa ity's Phone: - <br /> 9a.1 9b.U.S.DOT Description(inducting Proper Shipping Name,Hazard Class,ID Number, 0.Containers 11.Total 12.Unit <br /> HMI 'and Packing Group(if ary)) 13.Waste Codes <br /> o. Type Quantity Wt.Nd. <br /> W <br /> W2' i•.1!�J3.ti... r•, � -`( :'s €r` T I� I T ._:VI - <br /> C7 <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> Ch1.-PGI FY- F.fTFr i'rInt- 4- t t <br /> ' <br /> i F?}-. t �It' A.-J,-J t_r;r : st-;:n. e f-. - ,fir is�, <br /> 15. GENERATOR S10FFEROR S CERTIFICATION. I hereby declare that the contents of this consignment are fuky and acci rately described above by the proper shipping name,and are classified,packaged, 4 <br /> marked and labeledlplacarded,and are it all respects in proper condition for transport according to applicable intemation and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAeknowiedgmenl of Conant. <br /> I ' that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b}(if I m a II quantity generator)is true. <br /> G to Offerors Print ypecl Name Signature Month Day Year <br /> L" 7 f <br /> J 16.lntenr 'oral hipments <br /> z ❑Import to U.S. ElExport from U.S. (;rt ontrylexit:Transporter signature(for exports only): eaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> TmWer 1 Printedrr Name Signa Month Day Year <br /> A CLU 16 1-7 l <br /> Tr r 2 p ntedlTyped Name Signature Month Day Y)sar <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Borence Number: <br /> G. 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> L1 <br /> FaciItys Phone: <br /> LLj 18c.Signature of Atemate Facility(or Generator} Month Day Year <br /> 1a <br /> z ' <br /> LU 19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 1' � 2. <br /> rC� <br /> 20.D4ignated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Sig Month Day Year <br /> 1 <br /> EPA Form 8700.22(W.12-11 Previous editions are o e. DE G ATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />