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Sep 07 11 11:32a Dawn Wickman 715-E98-3485 p•2 <br /> Please print or Pipe.(Form designed for use on elite 02-pl typewriter.) M Form Approved.-OMB No.205D 0039 <br /> UNIFORM HAZARDOUS I lawraraW ID Number 2 2.Pagelcf 3.Emergency Response Plrore7000850548 <br /> O.Manifest Tracking Number <br /> WASTE MANIFEST A [ ®00 a 4 ? •l -/� 559-977-6282 0 0 0 8 5 0 5 4 8 G B F <br /> S Ge r�tosWame and MaiYng Address Genealor's Site Address(if different than mailing address) <br /> - Lk-—Som.Lv-o,J <br /> CLAfle– <br /> Genealcls l'Ifo ieoe,C+ur..7 OY• 96aoS qD 4/0 ` /FJ7 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> CRI R6`gF—dIria Sem CE iriC WihC?`nnnn,>Q7� � <br /> T.Transporter 2 Company Name U.S.EPA,ID Number <br /> S.Designated Fad try Name and Site Address U.S.EPA ID Number <br /> CRI Recvciinq Service Inc WIR000 2976 <br /> 101 Hagen Dr <br /> ftjie, h1A 54028 8011247 2004 <br /> 9a. <br /> 9b.U.S.DOT Description(iocW6ng Proper Shipping Name,Hazard Class,ID Funber, 10.Containers11.Total 12.Unit 1a.waste Coos <br /> HM and Packing Group(if arn);; No. Type Quantity Nfthnl. <br /> Nort-RCRA Hazardous VVaste Solid 1 M lobe p z3 <br /> z 2. <br /> W <br /> 3. <br /> 4. <br /> . t <br /> 14:SpeUal}i�Nng InshV430na and Additlanal Infonna8cn <br /> VKeaTPiUtective Clothing and Eyewear. 9.1 -OILYABSORPENT E_R.G.-5.1 #171 <br /> 15. GENERATOR'S/OFFERORSCERTFICATION: :hereby dedlare that the contents of bis conagnmenl am fully and aravratey described same by the proper shipping nane,and are daseffied,packaged, <br /> marked and Iabekdplacorded,and am In all respects m proper condeion fatansport acvcrdng to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify IW rhe contents of M¢cougment conal to lis toms of the attached EP,4AdImawlecill of Consent <br /> I derby#0 the weds mirdm¢ation statement idenl0ed in 40 CFR 26l(d l am a large quznttygeleratal)or rb)Ig l an a ema't quantity generaW,is lme <br /> •e mto'slOrwors PriNed7lypetl N Slgna4.re Month Do - fear" <br /> 3� oq- <br /> F . - ❑Import to U.S. Pon of enhyezC - <br /> z, Tarsporlsr slgnahra.(far exports only), Dote leceong U.S.: <br /> w 17.TmnspomerAWpwledgne at of Receipt of Materials <br /> zi Tanspaler l Printad,i Jame Signature ^ ^ Worth gDayF .Year <br /> RTreWoder 2 Printedflypod Name Signahae Month Day Year <br /> C " <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Duardty ❑TYX ❑Residue ❑Partial Sell ❑Full Ncclion <br /> Mandrasl Reference Numoer, <br /> l8d.Alternate Facility for Gexratodl U.S.EPA ID Number <br /> J_ <br /> V <br /> r+a- Facility's Phone: <br /> 18c.signature erAkmWe Facifly(of Generator) - Mcnth ]ay Year <br /> w <br /> Q <br /> z <br /> N19.Hazardous Waste Report Management Method Codes(Le.,cod%for hazardous waste trealmem,disposal,ar6 recycling systems) <br /> a 1_ 2' 3, 4 <br /> HIM - <br /> 20.Designated Facility OATw a Operator..CeNl¢a'mn of receipt dhazardous materiels covered by the manifest except as nicked In Item 18a - <br /> Pd tecIT&WNam, �, Signaun Month Day Year <br /> K <br /> "'a EPA Form 8700-22(Rev. -05) Previous editio s are obsotale. . <br /> r DESIGNATED F CILI DESTINATION STATE(IF REQUIRED) <br /> 1, i:• .:' <br />