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Apr 09 12 10:07a Dawn Wickman 715-698-3485 p.4 <br /> Please printer type.(=orm designed for use on elite(12-pitch)typewriter.) Forth Approved_OMB No.2050-0639 <br /> UNIFORM HAZARDOUS 1j - e,,1r1DNu G �cLimbcr 12.Pagelof 3.Elnergen:i Response Phone 4.16anflest Traokinq Number - <br /> WASTEMANIFEST �(�C>�3t • JJK <br /> 5.GenefatNs Name and Vaih g Addrass Gererabes Site Address('d different than nviiiing addrass) <br /> Genergor's Phone <br /> 6.Transporter 1 Company Name U.S.EPA IG N Rrrher <br /> 7.TranspcAer2 Company Name U.S.EPAIG Number <br /> B.Designated Facility Name and Si:e.AdJlfess U.S.EPA ID Number <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Desnription('mchuding Proper Shipping Name,Hazard Gass,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Gran(if any)) No. Type Quantity ImL N1L <br /> L% <br /> s 2. <br /> w <br /> t, <br /> 3. <br /> THIS <br /> ERTi� ATE l <br /> t <br /> a- OF R -- ' l 1 <br /> 14.Speaai Handing lrstrxWn3 and Additional lnformati • - "" <br /> Ck <br /> 15. GENERATOR'S10FFEROR'S CERTIFICATION: I hereby decare that the mrards of this consignment are nilly and accrratety described above by the proper shippirg name.and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects In proper oond'ition for transport according to applicable irtlenra6oral and national govemnentd regulel'ors.!f eacport shipment and I am the Not" <br /> Fxpcster,'certify that the contents of this.consgnrneent conform to the terms of the attached EPA AckrovAedg hemi of Consr4rt. <br /> I ceriliy that the waste minimization statement identified in 40 CFR 262.27(a)(it I am a large quanBy generator)of(b)'(fd'am asmal rig antity generator;is true. <br /> CeneratorserointedlTyped f•(ame F Signature ;. Month Day Yea <br /> jr's Prr <br /> ,4? <br /> r 18.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entryiexit <br /> z Transporter sicneture(forexpors Dnly): Date leaving U.S.: <br /> Of 17.TranspoterkknoKledgrnento(RecuptofMa!e!als <br /> F" TransporterIPrirdedrryp�e,d-&Wrne f-� Signahaa -! <br /> ar� (f- :1 y +�f 4" {r �^C. ,J}s <br /> M <br /> Transposer 2 PrintediTyped Nae Sigrnalu a Monti Day Year <br /> _ <br /> 18.Discrepancy <br /> 18a.Discrepancy Indration Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Aite-nate Fachly for Generator; U.S.EPA ID Number <br /> 1 <br /> iJ <br /> LL- Facility's Phone: y <br /> S 1W Signattire of ldternate Fac.lily(or Generatc-) Month Da Yea <br /> Q <br /> Z <br /> u19.Hazardous W3sle Report Mar•agement hlethod Codes fi.e.,codes for hazardous waste treatment,disposal,and recycling system;) <br /> Wn 1. 2 3 4. <br /> 20.Dcsigiated Facility OwnJr or Operator.Certification of receipt of hazardois materials covered by the manifest except ss rioted in Item 18a <br /> Nntedr'fyped Name Signature IVIG" Day Yen <br /> EPA Form 8700-22(Rev.3-05) PrevioL s editions are obsclete. DESIGt4AXED FACILITY T-0 GENFR AT! <br />