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Please Drint or Woe. tForin dpqinn,-d f6rilea nn Pilla (119-n'ltphl funaturltar I <br />-- <br />LPA form 1d1W-ZZ(KeV.J-Ut)) Previous editions are obsolete. <br />DESIGNATED P—ACILITY TO GEN-"—ATOR STATE (IF REQUIRED) <br />7� <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page I of <br />13. Emergency Response Phone4. <br />Manifest Tracking Number <br />WASTE MANIFEST <br />1 2' <br />424-9300 <br />0 U 1" 6 JJ K <br />5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) <br />0111414:71; LUME- PAI <br />1130 N. hqm-d N ST 11, 9) N &014 N S T <br />NJOIVE'GA CIA 0-75,11"M. 0A f -X' --1X48 <br />Generators Phone: 2M -Z3"9-0F;6r5 <br />6. Transporter I Ccmpany Name U.S. EPA ID Number <br />GBILRY F'PAPIRONK14TAL SEFT-VICES <br />AA C A B 0 2 ; 7 7 0 3 6 <br />T—Transporter 2 Company Name U.S. EPA 10 Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />FAMS ENVIRCIAOVENTAL \J v(z�� <br />WEST SAGRAWN'TO CIA, WIS Y 1 <br />C A D 0 4 4 0 0 3 5 5 6 <br />Fadlit es Phone: Vis)371-5747 <br />9a, <br />91b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10, Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (If any)) <br />Quantity <br />Wt.Nol. <br />W <br />0 <br />1. <br />W <br />9 <br />NICA-11GRA KAVIROGLIS WKSIE, LIQUID (THLY W xmm) <br />0 0 1 <br />41, <br />1 <br />Z <br />2. <br />LU <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />NAERO# N' '17 1 ' P R OR t; E # OB I 'JVPR OP RIArE PER, 6 ONAL PR 0 -MOTIVE EQUI PNt',,141 <br />11 <br />N\\ 7- <br />Vic <br />15. GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents 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 according to applicable international and national governmental regulations. It 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 statepentidepu�qd.iq-40 CFR 262.27(a) (it I am a large quanttliygene ptor) or (b) (if I am a small quantity generator) is true. <br />I �Srqiature Month Day Year <br />rator's/OffY' t N eC - < "'1 'q t' " y <br />e Id <br />-a <br />ll�- <br />16. Interiq ro r-- <br />AM'Iefg Export from U.S. Port of entry/exit: <br />K. <br />Transporter signature (for exports only); Date leaving U.S.: <br />IX <br />LLI <br />17. Transporter Acknowledgment of Receipt of Materials "N <br />TranslporttIPffnled[Typed Namesignature X Month Day Year <br />- I Y-21 1 <br />0 7 1 <br />;Z it <br />Transporter 2 Printed/Typed Name signal0fe V Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ TypeEl Residue Partial Rejection Full Rol action <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA 10 Number <br />Facililys Phone: <br />Uj <br />18G. Signature of Alternate Facility (or Generator) Month Day Year <br />-19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LLI <br />C3 <br />1 1 <br />.AIA/1110 <br />1 <br />2. <br />1 <br />20. Designalted Facility Owner or Operator: Certification of receipt of hazardous materials covered by the man�tqcept noted in Item 18a <br />I n <br />Pd' eg/,J rid Name gma P1Month Day Y91, <br />'T <br />AL L <br />LPA form 1d1W-ZZ(KeV.J-Ut)) Previous editions are obsolete. <br />DESIGNATED P—ACILITY TO GEN-"—ATOR STATE (IF REQUIRED) <br />7� <br />