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0 0 <br /> Please print or type.(F&m designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 r ID Number $�}�/� 2.Page 1 of 3.En en Response Phone 4.ManNest Tracking Number <br /> WASTE MANIFEST LOO 0180 b' 55 -. 77-6282 O J J 412 3 9 2 G B F <br /> 5.Gene dMailine Add 1el Generators Site Address(if different than mailing address) <br /> 3 � CNL�1�Vr�1�C - `�` <br /> Generetors Phon Q tv - `. 0 <br /> 6.MWEV 1% service Inc a Wff '©00029751 <br /> 7.Transporter Company Name U.S.EEpPA�lDrNlyurymbeerr <br /> 6.dRIaW9li5W9bm!9 MrA'inc U.sA <br /> 101 Hagen Dr YYIKVV00297rJ <br /> Woodville, Will 54025 WC-241-2004 <br /> Fault esPhone: <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Parking Group(If any)) 13.Waste Codes <br /> No. Type Quantity Wt./Vol. <br /> 1. <br /> R Non-RCRA Hazardous Waste Solid DM 11LIP <br /> P <br /> R <br /> Z 2. <br /> 3. <br /> 1aW"ii'P1k1*LWfIWEl61%91'6'*4'Eyeweair. 9-1 -OILYABSORBEM E-R.G.-9.1 #171 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurotety described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(81 am a large quantity generator)or(b)(if I am a small quantity,generator)is true. <br /> Generatory0fferors Pdntedrfyped Name Sign" A7onth Day Yea <br /> (� o <br /> 16.fifiturnbrIldnal Shipments <br /> _ E-1Import to U.S. ❑Export tram U.S. Port of entrylexh: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.4 nsporterAcknoxkdgment of Receipt of Materials t <br /> OTrain i r 1 PrintedR p crone Si net Myny Day Year_ <br /> 4 Tran rter2 PrintedR Nama <br /> Signature Month Day Year <br /> C <br /> H <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indicalion Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> %x <br /> LL Facility's Phone: <br /> 180.Signature of Ahemate Facility(or Generatoo Month Day Year <br /> Q <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1.Hm 2, 3. 4. <br /> 1 20.Designated Feel 4 Owner or Operator.Certification of recelpt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PnntedRyped Name Signature MOnth Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> DESIGNATED FACILITY TO GENERATOR STATE(IF REQUIRED) <br />