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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Farre Apptavetf OMB No.250 p�39 <br /> EfNlFORM HAZARDOUS 1.Generator JI)Number 2.Page 1 of 3.Emergency Response Phone 4.M T ng N m <br /> WASTE MANIky <br /> FEST " '" �r r,1 6 JJ K <br /> 5:Generators Name and Marring Address Generators Site Address(idrtferent than malting address) <br /> r!i]trtti`MN C.;.. i. , <br /> Generators Phone: ; -,7 f�► = <br /> 6 Transporter 1 CompaWName <br /> LA1'Wjr ,`GQ U.S.EPAfD Number <br /> 7 Transporter 2 Company Name <br /> U.S.EPA 10 Number <br /> 8 Design�E�r.-faa7ata dije��gs�`1'u <br /> U.S.EP, N be <br /> r-4 F:- DF1�t:E AGE Lit fi: :k ` <br /> Facirj ys Phone: <br /> 9a. 9b:U.S.DOT Description{including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM aiid Packing Group(d CluTotal <br /> Na. Type t]antity arty)) mitt WWd.12.Unit 13.Waste Codes <br /> " - <br /> V 1. morlt9t•t,:r'T t IVASTE CUD Taf1s 3t?x =•1 MI t. <br /> O <br /> L <br /> 2. <br /> 3. <br /> 4 <br /> 14.Speclaf FfantlGng Instructions and Additiortar Information frrFiLEs <br /> cr�x?e;71 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately desoibed above the <br /> marked and labeiedlplaCarded.and are in all respect in by proper shipping name,and are classified,I am padrary <br /> Proper to the a for transport chied E A m applicable ent of <br /> and natkrnal governmental regulations.H export shipment and I am the Puimary <br /> Exporter,I rBrtify that tiro canter>ts of this consignment Conform to the terms of the aCadred EPAAclauawledgment of Consent <br /> I ce"that the waste minimization statement Identified in 40 CFR 252.27(a)(d I am a large quantity generator)or(b)(if f am a small quantity generator)is true, <br /> Generators! es PdntedlTyped Name SignatureP' r2E <br /> Month Day Year <br /> �w � / r4 rJ 17' <br /> F 16,In emationa Stuprnents <br /> Z Transporters'signature far ❑lmpat m U S ❑Eiport from U,S. Pari of entrylexib <br /> gn ( exports ody); <br /> LW <br /> 17.TranspaterAdmow7edgrnent of Receipt of Materials Date U.S <br /> T answasi_ Na Signature 1J <br /> ' (1t k Day Year <br /> `" 4' rJ !7 <br /> Transporter2 PrintedlTyped Name Signature <br /> Month Day Year <br /> 18,Discrepancy <br /> 18a.Discrepancy IndipSon Space <br /> OuanttyType Residue ❑Partial Rejection <br /> ❑Full Rejettian <br /> 18b.Altemaa Faa1 ty{ar Generator) Manifest Reference Number: <br /> —+ U.S,EPA ID Number <br /> U <br /> W FacTitys Phone: <br /> W 181.Signature 01Artema a Facility(or Generator) <br /> Z Month Day Year <br /> S2 19.Hazardous Waste Report Management Method Codes e.Bodes for hazardous waste treatment disposal,and recycling systems) <br /> 3, 4. <br /> 20.peji natgd Facitity Omer or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in item 1 S <br /> Put yprr ame <br /> ^rfl, Signakrr Month <br /> ay Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. — ✓ _ ! _ <br /> TRANSPORTER'S COPY <br />