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GTSE•. Ut.11.�1.. 1.375 <br /> Farm Approved.OMB No.2050-0039 <br /> Please print or Cape.(Form designed for use on elite(12-pitch)typewriter.) <br /> . <br /> UNIFORM HAZARDOUS / � QJNO 2.Page 1 of 3.Emergency Response Phone d.Ma nit est Trackln Number <br /> WASTE MANIFEST "� /pa ��i� `T"a 559-97Z�282 0 0 0 5 0 425 G B F <br /> 5.Genemi Name and Malmg Address Generators Site Address(I different Nan mailing address) <br /> }edge4"D t s F_ P.2 1 F.-1 QST RaPA,(2 <br /> i a 90 Rd� OtAF-+cn R7 <br /> c CA <br /> Generators <br /> ,If,9°°�.r�cyc9Ing Service 1.nc IuWIR660029751 <br /> 7.Transporter 2 Co tmym <br /> pany Name U.S.EPA ID Nuber <br /> aag Vain Service Inc U.S.EPA IDNumber <br /> 0 n Q 7 i 51 <br /> 101 Hapen Dr W!ld0002., <br /> Woodville, WI 54028 1300-241-2004 <br /> Faalitys Phone. <br /> ga 9b.U.$.DOT Desaipoon(including Proper Shipping Name,Hazard Class,ID Number. 10.Canlainers 11.Total 12.Unit 13.Waste Codes <br /> HMand Packing Group(it any)) Type QuantityWLNoI. <br /> 1 23 <br /> Non-RCRA Hazardous Waste Solid 3m 3 P <br /> z 2. <br /> W <br /> x7 <br /> 3 <br /> 4, <br /> 16 Spedal H'=glnsbuc0ars and AddNonal Information <br /> WearPrntectiveClothingandEyewear. 9.1 -OILY ABSORBENT E.R.G.-9.1 #171 <br /> Xy -. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare mat the contents of this consignment are fully and awumlely deserted above by the proper shipping name,am are classified,packaged, <br /> marked and Iabeledrylecarded,and are in all respects in proper wndition fortransport according to applicable internationNand national governmental regulations.It export shipment and I am dw Primary <br /> Expader,I calmly that the contents of ahs wasignment conform to the terms of the attached EPAAcbwwledgment of Consent. <br /> I party that the waste minimGation statement identified in 40 CFR 262.27(x)(if I am a large quantify generator)or(b)(ifI am a small guanbty generator)is we. <br /> Generators101kmrs Printed/Typed Name Signature Month Day Year <br /> r�A%?_LVSKQ /J;-7 C' <br /> F 16.Interrupted Shipments E]Import to U.S. LJExport from U.S. Pat of entry/exit <br /> = Tmnsportersgnmure(forexporsonly): - Dale leaving U.S.: <br /> w 17.TratspwMAcknoafedgment of Receipt of Materials <br /> Tmns1>oner -nledRypad Name <br /> Sign re Monro Day Year <br /> w 9C c».9+w if vs <br /> 4 Transporter 2 Printedlryped Name Sgnalum Month Day Year <br /> K <br /> H- <br /> 16.iiscrepancy 1 BeSia.Discrepancy Indication Space ElDumbly ❑Type ❑Residue ❑Partial Rejeclbn ❑Full Rejection <br /> Manifest Reference Number <br /> 1 By Alternate Faaliry(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Faaltrys Phone: <br /> W 1Be.Signai of Alemate Faally for Generator) Monty Day Year <br /> H <br /> Z <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hmebus waste veabnen4 disposal.am recycling systems) <br /> O 1. 2 3. d. <br /> 20.Oes'gnaled Facility Oxnerw Operator CeN6ralion of recegt o/hazaNws materels wvered by the manifests nand!in Item Ba <br /> 1 Pr n ype l Name lure Monty Daily Year <br /> �0 <br /> EPA Form-8700-22(Rev.3-0Previous edi' Bare obsolete. <br /> 10619.0178 DESIGNATED FAC,-MF O STINATION STATE(IF REQUIRED) <br />