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Apr 09 12 10:06a Dawn Wickman 715-698-3485 p.2 <br /> Please print cr type.(Form designed for use cn elite(12.0tch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator DHumher 2.Page 1 of 3.Eme genuy Response Phor.e 4.Manifest Tracking Number <br /> ` 1 ) ri J <br /> WASTE MANIFEST -r 'Y � <br /> 5,Generator's Name and klachng Address e F `/' %t '1 r Gurietators Site Address!d difkrent than mailing address) <br /> Generators Ptwne: <br /> 6 Transports-1 Co;i%l .y Nana U S-EPA ID Nu 1t r <br /> 7.Transporter 2 Cornpany Narne U.S EPR ID Number <br /> 8 Designated Fac lily Name and Sae Address U.S.EPA ID Numbar <br /> Faralrys Phone? - <br /> ga 9b V.S.DOT Descriplim(including Proper Shipping Name,Hazard Cass,ID Number, 1 C.Containers ti,Total 12,Unit 13 Waste codes <br /> HM and Packiy Group rd any)) No. Type 01antily MJVol. <br /> 1. <br /> � �'3;. '•'i: -•-eta. ,,: - - - _}:r -..-- -- <br /> _ <br /> z 2. <br /> w <br /> THIS COPY IGS YOUR <br /> BERTIFI3. <br /> OF RECYCLING <br /> 4 BY_- <br /> 14.Special Handling lnstruIXbnsand Addilional Information <br /> 15. GEN ERATO R'SJOFFEROR'S CERTIFICATION: I hereby Ceclare that the contents of this cons gnment are fully and accurate',y describes above by tho proper shipp ng name,and are classified,packaged, <br /> marker aid labelediplacarded,and are in all mspexs in proper condition for transport according to applicable intemationaland nation govemmentl regulations.If export shipment and I am the Frimary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the at:acted EPA Acknovaedgme-d of Consent. <br /> I certify that the waste minimzzbon statement denti'ied„n 40 CFR 262.27(a:(e 1 am a targe quantity generatoI or Ib)i if I am a small quantity generator]is t ue. <br /> Generator s/O ferors Pdrited.'Typed Name �k Signalise Month Day Year <br /> --j 16.International Shipments <br /> V— E Import to U-S. ❑Export from U.S. Port of erltry,exit: <br /> z `cors Grier si nalure ore arts enl <br /> p g (`. exports y Dale leaving U.S.: <br /> LW 17 Tmnsporter A.cknowledgmwt of Receipt of Materials <br /> 0!: Transporter 1 PrmtedrTyped Name Signature Month Cay Year <br /> z 41 <br /> Transporter 2 PrinteldfTyped Name Signature L� C��� 1 Month Day Year <br /> 18.Discrepancy <br /> 18a.Ciscrepancy IrOicabon Space ❑ Quantity ❑Type ❑Residue ❑Part al Rejedion ❑Full Rejecticn <br /> Manifest Reference Number: <br /> 18b.Atternwe Fadicy;or Generator) U S EPA ID Number <br /> v <br /> Li- Facility's Phone: <br /> ow 18c.Signature of Allernate Facility(or Generator} Month Day Ye <br /> Q <br /> z <br /> V3 19.HaMrdous Waste Report Management Method Codes fi.e.,codes for hazardous waste treatmen(disposal,and recycling systems) <br /> n 1. 2. 3. d. <br /> 2C.Designated Facility Owner or Operator.CertJfimtion of recepl of hazardous materials covered by the manifest excepl as noted initerq 18a <br /> Priwed/Typed Name Signatore Month Day ye <br /> EFA Form 8700-22 iRey.3-05) Previous editions arq obsolete. DESIGNAXED FACILITY TO GENERAT <br />