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Please pi'in1 or type. Form Approved,OMB No.2050-0039 UNIFORM HAZARDOII Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST SKS S.Generator's Name and Mailing Address Generalors Site Address(it different than mailing address) _ u n u r Generator's Phone 6.Transporter 1 Company flame 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 Descripb'on(including Proper Shipping Name,Hazard Class,ID Number. 10.Containers 11.Tola! 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt.Nol. Z 2. W ca 3. 4. 14.Special Hanc ing Instructions and Additional Information _.RR Nil YN-yep-1760-t,ll ;�►,..'1 --Ldnt r act rot ained by gin ii or, Cott torb i4gQflcy dutht,{ fin ",.r7:r Eat t %1 " :11f1'^^t E+r r 0 4dri lir'' dig-I f34�'.Y!!s'� �t;;r�t � l Jh.' i =i :i,i� ail-. :1: Fr> .t!'• � -� 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,aril are classified,packaged, marked and labeledlpiacarded,and are in all respects in proper condition for transport according 10 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 EPAAcknowledgment of Consent. I certify that the waste minimization statement identifed in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator's)Cfferor ss pnntedlTyped Name Signature Month Day Year _j 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entrytexit: _ z Transporter signature(for exports only): Date leaving U.S.: ix 17.Transporter Acknowledgment of Receipt of Materials ur 6 Transporter 1 PrintedfTyped Name Signature Month Day Year CL z Transporter 2 PrmtedlTyped Name Signaiure Month Day Year ti 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Facility's Phane. LL, 18c.Signature of Alternate Facility(or Generator) Month Day Year a z 19 Hazardous waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU li 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 Printed/Typed Name Signature Month Day Year I EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY