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Please print or typo.(Form designed for use on ellta(12-pllch)typawdter.) Form Approved.OMB No.205HO39 <br /> UNIFORM HAZARDOUS 1 Gc-raraW lD Numhp GGGA 2Papel of Enve rvy Response Phone A.MaNdoalTmaking Number <br /> WASTE MANIFEST ���J� IL ,.SU - 015384275 'dJK <br /> 5.Denounces Reheard Wong Ad'9es neral. s Site Achim(if digerenl han mailing addmss) <br /> S t2EFtott0GS-toG �TDnJ C,&,. 95,2-15 <br /> onanlafs Plsda. �ll � C <br /> 6,l rans'pu:lor I Cunrpmry Name U.S.EPA IO Number <br /> CRP-- z� 22 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B,0esgFade Napand SdeAd ss U.S. PW Number <br /> LA-Sed ?Ga✓o&-,l <br /> / �iq rD A &6 TT`/ <br /> QS, 1111 S- OF &C/`?Tryp n.FVXtoA 99OD3 <br /> Facility's Phone: ZO O— — L'1 ocoU _ <br /> Sa 9b.U.S.DOT Destmpbon(h¢kxting Proper Shipping Name,Hazard Class,ID Number, 10.Came are 11.Totel 12.Unit 13,Wasle Codes <br /> HM and Padtlng Group Qlarry)) No. Type Quantity W(Nbl. <br /> �v14 3oz-7, d-hnaRoo(A-5 �OTEa 5oc,(o, fxpZl t g(� <br /> o r <br /> C� 0 C ,F 4I <br /> w iw 2. <br /> 3. <br /> 4 <br /> 1 GpaantHdrdumllnnwa0a,samAddii mlWwmaion !© Gl4lJl17�AS <br /> bS�l <br /> 15. GENEI7ATOR'SIOFFEROR'SCERTIFICATION:Inarehythdanothilbeconlenls al this consignment emfultyend accurately described of by the proper OAppig name,and are dassifed,packaged, <br /> marked and tabeledrplawrded,and ae hall respects In properoondnon for transport according to applicable IMemalional and national governmental regulations.Ilexpod shipment and I am the Primary <br /> Eapornw.I cerliy that the contends of He swelgnmenl conWrm to the terms of the attached EPAACmowledgmenl of Consent. <br /> I eorlily ihal the waste minimization statement identified In 40 CFR 262.27(a)911 am a largo quantity gonaator)or(p)(iR am a small quanlby gpaWnlm)Is We. <br /> Genere1n151DfiercdsPtlnledrfyp40 Norms Egm,lua Manlh Day :Year <br /> �o b fo <br /> J IS.International Shipments <br /> p_ 11 Import to U.S. ❑Expel from U.S. Purl of enirylexi[_,-__^___-____________ <br /> Transporter signature(for exports only): Dale leaving U.S.: <br /> w 17.TmospodorAdvomvledgmenlo( a[Aleteflas ' <br /> TrmmjK,lnr 1 PdnteN l Nea Name Signature Month Day Year <br /> CL <br /> CTmnspoder 2 Prmled7rypad Name Signaturt,01 IMonth Day Year <br /> W <br /> F– <br /> T19,Discrepancy 1� ^iD I—� <br /> 1 <br /> 19a.Discoepancy Indication Space L.J Ouanlily ❑ pe 3U� EDD ElPadml Rejection LDFORejecdon <br /> Rafo nnco Hurnbe <br /> 1 go.Alternate Fadily,(or Generator) +• • ok 2W U.S.EPA ID Number <br /> J <br /> LL FaIDly-,Phone: �YViFt�NNEv)hLF1&"STH <br /> w 18c.Signature olAberm,le Fatuity(u Generator) J. ', Monfn Day Year <br /> 6 <br /> z <br /> 05 19.Hazardous Waste Report Management Method Codes(Le-codes for hazardous wasle treatment,disposal,and recycling systems) <br /> 7. 2. S. T- <br /> 20,Desgnaled IFFaacclily Owneror Operator Codification of receipt of hazardous materiels covered by the manifest eNopt as noted in Ilern No <br /> not ,me Skpa A Daq Year <br /> FPA Form 0700- (Rev,3.051 Previous ')Inane are obw!rfe. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />