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Please print or types(For designed for use on elite('Itititch�writer.) • <br /> - Form Approved.OMB No.2050-0039 <br /> UNIFORM HAt71US 1. nepr�or PI Num r' � 2.Page 1 of 1 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFESTAt.-- <br /> 669-977-6282O' 3 2 3 6 2 G B F <br /> S.Gone ors <br /> Name andM iliogAd sL Generators Site Address(it digeren(than mailing address) �r <br /> 3q/l�}n eC/ii fll� lc7L) give <br /> Gene rfetd PA6s nb`F...f'.(}� r'r <br /> 6. ra rsporter l Company Name ` ! C� _ <br /> U.S.EPA 10 Number <br /> CRI RecyCii Service Inc WIR000029761, <br /> 7,Trenspoder 2 Company Name " U.S.EPA 10 Number <br /> 8.Designated Facility Name and Site Address U.S.EPA 10 Number <br /> CRI Reovin inn Service Inc 4IVIR®©00 9759 <br /> 101 Hagen Or <br /> Fe payolle. Vt4 W28 8W-241-2004 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Comainers 11,Total 12.Un8 <br /> HM and Packing Group(Many)) No. Type Ouanbry WI.Noif 13.Waste Codes <br /> 0 NowRCRA Hazardous Wash SOIJCI ' f DM 00 P 223 <br /> w <br /> X z. <br /> 3. <br /> 4. ter <br /> 14.Special Handling Instructions and Additional I ion <br /> WearPrntective Clothing'arid Eyewear. 9.1 -OILY ABSORBENT E.R G.-9.1 #171 <br /> 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, <br /> marked and IabeleciplacaNed,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.It export shipment and I am the Primary <br /> Exporter,I codify,that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certity that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeXner}blclOMaefs Printed/T arae nature t/ r Month Da Year <br /> J 16.Int agonal Shipments <br /> i— ❑Import to U.S. ❑Export from U.S. Pod of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w <br /> IT TranspoderAcknovAedgment of Receipt of Materials _ <br /> OTrans or Pdntcb/TName Signat Monty ay_ Year <br /> y � C7077 , Lk��� �>, , e , �y (0"3Z Transporter 2 PdntedrTYPed Name <br /> Signature <br /> Month Day Year <br /> rr <br /> t— <br /> } 18.Discrepancy <br /> Ise.Discrepancy Indiatlon Space ❑ Ouenfiy ❑Type ❑Residue ❑ParMal Rejection ❑Full Rejectbn <br /> Manifest Reference Number' <br /> 18b,Alternate Facility for Generator) U.S.EPA ID Number <br /> J_ <br /> 0 <br /> LL Fariliys Phone. <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 6 <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p L 2. 3. 4 <br /> HM <br /> 1 20.Designated Facility Owner a Oper ilor:Certification of receipt of hazardous materials covered by the manifest cept as n ed in Item 18a <br /> P'rsedR Name t Month Dg� Yea <br /> r (b/ D <br /> EPA Form 8700-22(Rev.3-05) Previous editio are obsolete. <br /> DESIQNATED F ILITYTO GENERATOR <br />