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• r • v <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) - Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1. ner ar N ber 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST �:Xlbbo" 026937 000 412158 G B F <br /> 5.Generato's Name and Mailing Address Genemmes Site Address(if different than mailing address) <br /> PICK-N-PLILL #- <br /> 3827 CLARK DRIVE': <br /> cense aTto�s re Nd C118S2p1�8'2'3t <br /> B.Transporter 1 Compary Name - U.S.EPA ID Number <br /> CRI Ryucling Service Inc 297 1' <br /> 7.Transporter 2 Company Name .S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> CRI Recvchnn Service Ino WI�i{j®®{}297'J1 <br /> �10z�1.�H,,4a��pen Dr <br /> Faairy-s"&ille, W 64MO 800-241-2004 <br /> 9a. 91b.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./Val. <br /> L <br /> Non-RCRA Hazardous Waste Solid DAA Uu) P 23 <br /> z 2. <br /> w <br /> 3. <br /> A <br /> 14.Special Handling Instructions and Additional Information <br /> Wear Protective Clothing and Eyewear 5.1 - OILY ABSORBW- E.R.G.-91A #171 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the wntwts of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport acceding to applicable international and national governmental regulations.If export shipment aid I am the Primary <br /> Exporter,I cedify,that the contents of this consignment conlonn to the terms of the attached EPAAtlmowledgment of Consent. <br /> I wr8fy that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)a(b)(N I am a small quantity generator)is true. i <br /> Generator'sl0funn's Pnntedrryped Name SignatureMonth Day Year <br /> ., a 1 .'.; <br /> lid r <br /> —1 16.bulawfiongrStitprinefts <br /> F ❑Import to U.S. ❑Export from U.S. Port of entry/axil: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> eu 17.TransporterAcknovAedgment of Receipt of Materials <br /> Traces ,der 1 Pdntedrryped Name S W Month Day Year <br /> 61 <br /> Transporter 2 Pnntedrryped Name - Signature Month Day Year <br /> C <br /> H <br /> 18.Discrepancy • <br /> i 18a.Discrepancy Indication Space <br /> ElQuantity ❑Type EJ Residue ❑Partial Relection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility for Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> W 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1. 2. <br /> 20.Designated Facility Omer or Operator Certification of rewipt of hazardous materials covered by the mangest ex n in em 18e <br /> lilt PntedfT ed Name SignalMonth Day Year <br /> e <br /> EPA Form 6760-Z2( ev.3-05) Previous Vitions are obsolete. I Liz' <br /> DESIGNATED FAG TO GENERATOR <br />