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i ,I-� ¢�` �Iilll�ill #1111 �#IIID#11{11 II <br /> Please print or type. 0 Q 7 1 Form Approved.OMB No.2050-0089 <br /> UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 of 3 Emergenq Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST tnW° r� t SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) a7 <br /> 6 <br /> Generator's Phone: } <br /> 8.Transpohi Com any Name 0.S.EPA ID Number <br /> INC <br /> a.o <br /> 7.Transporter 2 Company Name US,EPA ID Number <br /> i t,"t (•iY)i r ..r Fj C})i„ 7YVi.r ;t'. ;sJ� a ........<'r. <br /> 8.Designated Facility Name and Site Address W = ,-; v US.EPA ID Number <br /> �,k.�£a <br /> _ <br /> WA r `vis YA"a 1 Tiffs f'rf 3#37ah°'v <br /> Facility's Phone: � -� f�> <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity WtA01. 13.Waste Codes <br /> eY t _`-t ,'F;ks" rote = t "tr ytss:>c. ;):' <br /> f , ). <br /> a <br /> a 01 IY <br /> 6 <br /> W <br /> (7 <br /> 4 <br /> 14.Special Handling Instructions and Additional Information <br /> ? Ai <br /> 15 GENERATOR SIOFFEROR S CERTIFICATION. I hereby declare that the contents of this consignment are full and accurately described above b the proper shipping name,and are classified,packaged, <br /> 9 Y Y Y P P PP9 P r <br /> marked and <br /> rtify tatth conteandaremallrespects in proper to the ter for transport according toknowledgeentof international <br /> Cons and national governmental regulations.If export shipment and am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified In 40 CFR 282.27(a)(if I am a large quantity generator)or(b)(If I em a small quanffy generator)Is true. <br /> Generator's/Oe's Printed/Typed Name Signature Month Day Year <br /> jig I G� t d dl�3 I ! <br /> _i If.International Shipments <br /> 6. ❑Import U.S. ❑Export from U.S. Port of entrylexit: _ <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> U. <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Tr potter 1 Printed/Type(r,'.Name re Month Day Yearasc <br /> I. <br /> CL I <br /> Trans briery Pacterl ad Name �"' ' ^`;7, <br /> urMpt1 LaY i Teari <br /> i18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type El Residue ❑Partial Rejection ❑Full Rejection <br /> Mani/est Reference Number: <br /> 'Bb.Alternate Facility(or Generator) U.S.EPA ID Number <br /> i� <br /> rL facility's Phone: <br /> !u `Sc.Signature of Alternate Facility(or Generator) <br /> ;; Month Day Year <br /> -c <br /> ip19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> [] 1 2. 3.IL 4, <br /> LA <br /> r <br /> 20.Designated Facility Owner or Operator Certlfeetion of receipt of hazardous materials covered by the manifest except as noted In Item 18a : <br /> PIintediTyped Name <br /> Signature _ t <br /> 4 1 9 Month Day Year <br /> �__ i� t•-J,CA " � YE4[ :�� <br /> y X41 } .Zl p ,{ <br /> EF A Form 8700 22(Rev 1217) Previous editions are obsolete. DESIGNATED fACILITY TO EPi e-MANIFEST SYSTEM <br />