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Please brint or type. (Form designed for use on elite (12 pitch) typewriter.) Form Approved. OMB No. 2050-0039 (FORM HAZARDOUS 1 . Generator ID Number 2 Page 1 of 3 Emergency Response Phone Al. Marble I at T on:I king.,Number WASTE MANIFEST pSKS k* , d 5 Generators Name and Mailing Address Generators Site Address (if different than maiing address) Generator's 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 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 HM and Packing Group (if any)) No. Type Guard ty wt./vol. 13. Waste Codes 1 ) P I w 2. w 3. _._ .,_... . ..,,_,..:. 4. 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 (a) (ffl am a small quantity generator) is true. G rators/Offerons Prnted/Typed Name Signature Month. Day Year 16. International Shipments F ❑ Import to CJS. ❑ Export from U.S Pad of entrylexit Transporter signature (for exports only): Date leaving U.S.: 17. Transporter Acknowledgment of Receipt of Materials Trapsporterl Printed/Typed Name, Signature 7, Me tlth Day Year O y QTransporter 2 Printed/Typed Name N Signature .. Month Day Year a 18. Discrepancy • 18a D3I repancylndwahon Space ❑ Quantity ❑ Type ❑ Res ❑ enal Residue PRejection El Full Rejection + Manifest Reference Number ti 18b. Alternate Facility (or Generator) U.S. EPA ID Number YJ <ad Facility's Phone: 1 Ba Signature of Alternate Facility (or Generator) Month Day Year T19. Hazardous Waste Report Management Method Codes (he., codes for hazardous waste treatment, disposal, and recycling systems) 4. 20. Designated Facility Owner or Operator: Candi ton of receipt of hazardous materials covered by the manifest except as noted in Item the Hurled/T ad Name Signature Month Day Year EPA Form 8700 22 ,(Rev 3-05) Previous editions are°obsoletei DESIGNATED FACILITY TO GENERATOR i