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Please prinf or type.(Form desi ed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOU 1., ne tar N mb Q f� 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> .WASTE MANIFEST AL. 6p 1$$204 30 ')J ,J 4 i 7 8$G B F <br /> 5:'GeraatoCs Narne and Mailing Address Generators Site Address(if different thanmailing address) <br /> 'AC11 -PUU.'NSQ! <br /> 3Cl B�AR K DRIVi <br /> GenUto�s�PfiVNi 95206-5231 <br /> Transporter I CompAnyName U EPA ID Number <br /> CRI R "Service Inc ''WI�'tt WO"761 <br /> 7.Transports? Company Name U.S.EPA ID Number <br /> 8,Designated Facility Name and Site Address U.S.EPA ID Number <br /> CRI Recvolinp Service Inc WIR000029761 <br /> 7u/s1�0s�1� Hagen Dr <br /> Fapsne, W 54M SM-241-2004 <br /> gra 91h.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1. 3 <br /> Non-RCRA Hazardous Waste Solid DM P <br /> 10 <br /> Z 2. <br /> W <br /> CO <br /> 3. <br /> 4. <br /> 14.Special Handling Insbuctions and Additional Information <br /> Wear Protective Clothing and Eyewear. 9.1 - OILY ABSORBENT E.R.G.-9.1 0171 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name,aM are classified,packaged, <br /> marked and Iabeledlplacarded,and are in all respeds in proper condition for transport according to applicable international and national governmental regulations,If export shipment and I am the Primary <br /> Exporter,I cerfity that the contents of this consignment conform to the terms of the allached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 261(d I am a large quantity generator)or(b)(if I am a small quantity generator)is We. <br /> Geneatofs/Ogeors Printed(Typed Name Signature Month Day Year <br /> 1 1 <br /> 16.Intema conal Shipments <br /> LJF Import to U.S. ❑Export from U.S. Pon of entrylexif. <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknoxledgment of Receipt of Materials <br /> Tans er 1 Printedrryped Name Sjgnatgre ! Month Day Year <br /> QTransporter 2 Printed/Typed Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w 18c.Signature ofAJtemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3, 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manilasxcept as not in It 8 <br /> illl P'nt yped Na a Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous a itions are obsolete. 7 <br /> DESIGNATED FACILITY TO GENERATOR <br />