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P ase print or type, (Form designed for use on elite (12-pitch) typewriter.) 'Form Approved. OMB No. 2050-0039 y /A UNIFORM HAZARDOUS 1 Generator ID Number 2. Page 1 of 3 Emergency Response Phone 1'4manifest Tracking Number (� fd WASTE MANIFEST - - SKS le 5Gnerator's Name and Mailing Address Generator's Site Address (if different than mailing address) 1 c Generators Phone 6 Transported Company Name _ U.S. EPA IO Number „ 7. Transporter 2 Company Name U.S. EPA ID Number i 8. Designated Facility Name and Site Address U.S. EPA ID Number " t I Facility's Phone: ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers N . Total 12. Unit 13. Waste Codes HM and Packing Group (if any)) No. Type Quantity WWO1. 1 . - � 2. ,. A 3 SLP 1 , aIr c ri IN [� (, j 4. _ u I - 14. Special Handling Instructions and Additional Information e er I i 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping nameand are classified, packaged, marked and labeledduacarded, 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 46 CFR 262.27(a) (if I am a large quantity generator) or (b) (ifI am a small quantity generator) is true. G nerator`s/Ofieror's Printed/Typed Name Signature Month Day Year —J 16. International Shipments < ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: Transporter signature (for exports only): Date leaving U,S,: 17,Transporter Acknowledgment of Receipt of Materials " Transporter 1 Pdnted/Typetl Name Signature, , r, . '" - Mgnth Day Year O Tanspoder2 Pr ntedlTyped Namee 4i - Signature - Month Day . Year - �.— „ 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quandt y ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: ti 18b. Alternate Facility (or Generator) U.S. EPA ID Number Z] � Fagi,Phone: .� 18c. Signature of Alternate Facility (or Generator) Month Day Year 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 2. 3. 4. �. EDesrynpaetedaclty OwnerocOpermor Cedifipati of receipt of hazardous materials covered by the manifet xept as noted in Item 18ame Signature l Month.. Day Year EPA Form 8700-22 (Rev. 3-05) Previouseditionsare obsolete. - DESIIOwTr ATELD VkACI0✓V O ' 7i GIL u W It