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lease print cr type.(Form desj(nod for use on elite(112-pitch)typewriter,) Farm Approved.OMB No.20540439 <br /> gk,6Rm HAzARDOUS1 e or N bg� 2-Page 1 of 3 Emergency Response Phone d Manifest Tracking Number <br /> WASTE MANIFEST XC6 V 0 18 8 204 559-977--6282 1 0 0 0 i0 4 4 0 3 8 G B F <br /> 5 Generators Name and Malang Address Generators Site Address(if different than mailing addrdas) <br /> PICK-N-FULL *W- <br /> 7 CLARE{ DRIVE <br /> aT+f3C�C <br /> one:pN. CA W-05-8231 <br /> Generalora <br /> 6.Ttahspurtar 1 Ccmpany Noma U.S.EPA ID Number <br /> CRI Re tfin service Inc WIR000029761 <br /> 7.Trznsponcr 2 Company Name U.S.EPA ID Number <br /> 9.Designaled Facility Name and$Ile Address D.S.EPA ID Numbef <br /> CRI Recwllniq Service Inc # ��, �,� <br /> 101 Hauen Dr <br /> Fa 9&11e, WI WM "-2AI-2X4 <br /> 9a. 9b•U.S,VOT Description linduding Proper 5hippmct Name,Hazard Class,ID Number, iQ,Cor talners 11.Total 12 Unit <br /> HM and Packing Group(If any)) 13.We Ile Cedes <br /> No. Type Quantity WI.lVOI. <br /> 1. <br /> Non-RCRA Hazardous WasteSolid � DM 223 <br /> M 2 <br /> 3. <br /> a, <br /> 14.$peolal Handling 16sirucfions and Additional Information <br /> VWar Prrltecti•ve Clothing and Eyevrear, 9.1 OILY ABSORBENT E.RLC2s.-9.1 #171 <br /> 15. GENERATOR'SfOFFROR'S CERTIFICATION: l hereby declare that the contents of[hie consignment ata fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> madsed and 6abeladlplacsrded,an4 are in all resNcls in proper condition 10r UaftsPOrt according to applicable International and national govemmdnlal regulations.If export shipment and I am the primary <br /> Exporter,I cert]y that Iha canlenls of this consignment rrmform to the terms of the attached EPAAcknowfadgmenl of Consent <br /> I certify that the nista minimization statement identified in Off CFR 262.27(a)(if I am a lar9e quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneratorsrOffsmrs PrintedlTyped Name Si nature Month Day Year <br /> 1N 1F1 �r� � r A t o67 <br /> ff�� <br /> 6.Intemalional Shipments <br /> 0 I'm Ib U.S. Export from U.S, Pon of enlrylexit: ....... <br /> Transparter signature(for exports only): Date leaving U.S.: T <br /> w 17 TransporlerAcknoy4edgmentofReceipt ofMaterials <br /> Tran otter 1 Printad(Type I Name <br /> S1gPatur� Mc nib Day Year <br /> Transporter Frrnted yped Name 5 re alu <br /> Month Day Year <br /> OC <br /> 18,Discrepancy <br /> 16a,Discrepancy Indication Space <br /> LJ Quantity Type Regidue Penial Rejection Q Fuil Rejection <br /> t <br /> Manifest Re rerence Number: <br /> 16b,Alldmata Fac liry(or GenerelOr) U.S.EPA 10 Number <br /> c] <br /> LL. FacilitysPhone: <br /> w 18c,Signature ofAltertlela FadGty(or Generator) <br /> Month bay 'Isar <br /> 19 Hazardous Wssle Report Management MBthod Codes(i.e..codes for hazardous waste treatment,disposal,and recyclirp systems) <br /> 3, <br /> Hitt a. <br /> 20.Designated Fatality Owner or Operator.Cer(iflnation of reeaipt of hagardous materials covered by the manifest except as noted in Item 1f1a <br /> Prinledllyped Name ognature Monro Dey ear <br /> EPA Forel$700-22(Rev.3-05) Previous editions are obsolete. <br /> ,d 9650 QN DESIGNATED FACILITY TO GA 7 °�1)180(1 S A;--- DI <br />