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MISSOURI DEPARTMENT OF NATURAL RESOURCES <br /> ui 11itNr r I Ill r net Division of Environmental Quality <br /> I I(ikf lH 1111, FORM Aiil ON � EMERGENCY ttESPONSE <br /> 1 AI IAIF llTt f Waste Management Program [IS COASTGUARD <br /> P 0 Sox 176 Jefferson City Missouri 65102 Ae()414 gKop <br /> II ns! larll UI rill f 11 II I1` ,riFM1nrc <br />! I I tin , <,t nr fit In1t n 314-751--3176 ,Aaae�ayitlo <br /> 5 HAZARDOUS WASTE MANIFEST <br /> ul i r Or nAluRAL RLSOUR('LS <br /> J14 sla 7a7r, <br /> ase not nr type (Form design(d lot use on elite(12 pitch)typewriter) Form Approved DMB No 2(i500039 Expires 9 30 91 <br /> UNIFORM HAZARDOUS LCIA <br /> GeneralorsUS EPA ID No D Mnnde't o 2 P,ge Information in the shaded areas <br /> WASTE MANIFEST 1) S 11 ' R S 7 d of --1— Is required by Stale law <br /> 3 Genernlor s Name and Mailing Address A Missouri Manifest Document Number <br /> wA}mb wAumur GwwRsr im. 4 1 3 0 4 3 0 0 O 2 <br /> -y -y /�/� <br /> V-0 Bar 1727 B Stale Generator ID-other j <br /> Generitor s Phone 1 ' ► �l67�-7'0M St/ t-,ta3! cll i fornix 95201 <br /> i <br /> 5 Transporter <br /> t�I Co�mrpiniy Name w�LYV�T ny+[+ 6 USE P}A�ID Numlber C a q C MO Transporters ID <br /> CA 2463 <br /> E`Ai,1120"I ira'-'1F',R ! 2 SSSCM l�1 ES 1. A >11 i} V 8 ,5} ! 0 Transporter a Phone <br /> (209) 453Z71UF— <br /> Transporter 2 Company Name 8 US EPA ID Number E MO Transporier's 1D <br /> F Transporter's Phone <br /> Designated Facility Name and Site Address 10 US EPA ID Number G State Facility $D F '� <br /> ME KIESEL M, '1rA%,Ff M6124 <br /> ,#I B",nich Street HyFacdttysPhaid' � r t� r- �{����� Q <br /> CL <br /> St. Loui�r flingmuri 63147 }i 0 T 3 0 0 0 1 X 1 6 0 <;j 314) `421-0328 ; <br /> US DOT Description(including Proper Shipping Name Hazard Class and ID Number) 12 Containers 13 14 <br /> Total Unit I Waste No <br /> Ouantrty Wt/Vol <br /> a EPA WASTE CODE V <br /> r rlu�cnx, Rin lelte S0I111tion from tank clraanup, <br /> Nt7rj-R uta G 0 0 1 T C 0 1 0 6 0O <br /> i b EPA WASTE CODE Q <br /> I I= <br /> W <br /> i W <br /> c EPA WASTE CODE (rj <br /> EPA WASTE CODE. <br /> 'a <br /> Additional Descriptions for Materials Listed Abovet {J `Hai dling Codes for Woslea Listed Above Q <br /> cr_ <br /> O <br /> a <br /> V <br /> 45 Special Handling instructions and Additional Inlormahon <br /> It�t�ri71 �!u> r- into tarl'; car ACFX 84169 for tranaport. <br /> Z <br /> ac <br /> GENERATORS CERTIFICATION I hereby declare That the contents of this consignment are fully and accurately described above by proper shipping name and are classified packed marked � <br /> and labeled and ere to ail respects to proper cond+hon for hanspod by highway according to applicable international and national government regulations and applicable slate regulations W <br /> if I am a large quantity generator I cooly thv 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically practicable Q <br /> and Ihnl I have Viecfed the prtchr'tbtr rnrlhud of treatment slnr7ge or drsposii currently available to me which mm,mizes the present and luture threat to human health and the envtronmeot O <br /> OR ,f I am a small quantity generator I have made a good iadh efiorl to minimize my waste generation and select the best waste management method available to me that I can afford f— <br /> Pnnll�Typed Name Signature Month Day Year -� <br /> N <br /> Transporter 1 Acknowledgement of Receipt of Materials Date oa <br /> S <br /> Printed/Typed Name Signature Month Day Year <br /> 13111. DDrm. y ----% 1 0111 2 9 0 8 <br /> 1 Transporter 2 Acknowledgement of Receipt of Materials / Date la <br /> i Month Day Year j <br /> P mted/'fypee Name Signature 'i' <br /> / M <br /> i d <br /> Y <br /> CO) <br /> repancy Indication Space N <br /> Z <br />� U Q <br /> I Onq <br /> Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19 <br /> I Date <br /> (n <br /> rPrinted/Typed Name Signature Month Day Year Z <br /> LU <br /> F- <br /> uWs 3 <br /> rm 8700 22(Rev 9 88) MDNR HWG 10 PREVIOUS EDITIONS ARE OBSOLETE <br />