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Please pint or type.(Form designed for use on elite(12-pitch)Iypewnter.) Fortn Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 at 3.Emergency Response Plane4.Manifest Tacking Number <br /> WASTE MANIFEST L440 _ 0 0 0 7 715 3 4 G B F <br /> S.Gene ores Name and Maeing Address j! ,._ 1' _ f r pir '/. .+.�(• Generators Sile Address(A dinerent Van mailing address) <br /> ITS gswl <br /> Generators Pharre: <br /> 6.Transporter t C rnpnry Name U.S.EPA ID Number <br /> CRI Recycling Service Inc :�:as?�w������1 <br /> 7.TmnspWu 2 Company Name U.S.EPA ID mare <br /> 8.Designated Faulity Name and Site Address U.S.EPA ID Number <br /> CRI Recycling Service Inc WIR000029751 <br /> 101 Hagen or <br /> Faad>-a Plane Woodville,W 54028 ISD-241-2004 <br /> Its 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13 Wase Codes <br /> HM and Packing Group if ani No. Type Quantity 'Nt Not. <br /> ' <br /> Non-RCRA Hazardous Waste Solid biM W 223 <br /> z z. t7 <br /> W - <br /> C'J <br /> 3. <br /> 4, <br /> 14.Special Handling Instactions and Additional Information <br /> Wear Protective Clothing and Eyewear- 9-1 -OILY ABSORBENT E.R.G.-9.1 #171 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION!I hereby declare that are contents of this mnsgnment am fully and accurately descat e l above by the proper shipping name,and as classified,packaged, <br /> marked and MbeleNplacarded,and are in all aspects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I cenily that the contents of this consignment conform M Me terms of the attached EPA Acknoaodgment of Consent <br /> I artily that the waste minimupyron Statement identified in 40 CFR 262.21(a)(if I am a Large quantity generator)or(b)if I am a smatl n ty generator)is nue. <br /> GeniatoeOfferors Pnntecirryped Name Signa i Month Day Year <br /> )C 15 1 If log <br /> 6.mtemational Shipr�rents <br /> I- •s.,v ❑Import 0 U S. ❑Fxport from U S. Part of entry/exit <br /> =1 Tousporler signature(for experts only): Date leaving U.S. <br /> w IT Tansparfer Adurowedgmear of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Si Math Day Year <br /> h ?2 0 <br /> a <br /> TratIspi 2 PrintedrTyped Name t SignatureMonth Day Year <br /> K M <br /> r <br /> i18.Discrepancy <br /> 18a.Duagn pancy Indication Spam E:1 Dumbly 11Type ❑Residue EI Partial Reflection ❑Full Rejection <br /> MaNkst Reference Number <br /> 18b.Alemate Facity for Generator) - U.S.EPA ID Number <br /> J <br /> U _ <br /> LL Fadi Plane: <br /> W 18c.Signature of Allearate Facltity(an Generator) Month Day Year <br /> Zz <br /> 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and mci systems) <br /> C L 2. J 4. <br /> HUM <br /> 20.Designated Facility Carrier or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> 111 yped Name ' S Month Day Year <br /> SS5: its <br /> EPA Form 870622(Rev. 5) Previous editr s are obsolete. <br /> 10544.0597 DESIGNATED FACIL TO DESTI TION STATE(IF REQUIRED) <br />