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Apr 09 12 10:06a Dawn Wickman 715-698-3485 p.3 <br /> Please print o,"type.(Form designed for use on elite(12-pitch)typewdtec) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1'GenerabriD�iry��g 3 2.Page 1 of 3.Emergency Ras�onse Phone 4.lKanifestYrachingNumber <br /> WASTE MANIFEST 005744634 JJ K <br /> 5.Generator's Name and Alaiing Address Generator's Site Address 0 ckiment than mailing address) <br /> sloo�.Qn Cole <br /> 626 <br /> r. .... V5:0 <br /> Genarator's Phone: rr �' <br /> >I, y' <br /> U.Transporter 1 Company Name U.S.EPA ID Numter <br /> 7.Trdnsporier 2 Company,Name U S.EPA ID Numter <br /> R t(,v_ �Ca .�-nC . <br /> B.Designated Facility Nameand Site Add r s U.S.EPA IG NLImber <br /> 101i "Or. <br /> Facility's Phone. -. <br /> ga 91b.U.S.CCT Description(nclud Proper Shipping Name,Hazed Class,IC'Nimber, 10.Contalncrs 11.Total 12 Unit 13.Waste Codes <br /> HM and Packing Grahp(if any)) No. Type Ouan5ty WWd. <br /> 1. <br /> Q <br /> NK)IN, 510R,?k -'?LC <br /> n <br /> z 2 <br /> ul <br /> � •r^j•%.�li 4r' I.i <br /> rt�t 't'�Jnt�'l,Rc{.p <br /> C"�.'S9�iLr`ti4�1w <br /> 4 1A -7143110 <br /> 4. �, ... <br /> 14.Special Handlog Instructions and Addlional Information' <br /> --R104471 <br /> 15. GEN ERATOFMOFFEROWS C E RTFICA71ON: I hereby declare that the contents of this consig-xneM are loth/and accurately described above by the proper shipping name,acd are classified packaged, <br /> marked and labeledlplacard=Q"are in al respects in proper canditior for transport accorclng b applicable intemationand national governmental reguiatlois.N export shipment and I am the Primary <br /> Fxaorter, certify that the conteruE of this mnsianment conform to the terms of the attactued EPA Adcnouvledgment,r'Co}}��tri <br /> I certify that ghe waste minimization sfaterren identified in 40 CFR 26227(a)CO t am a targe quantity generatoir)or(b)(if l am a small quantity generator)Is OA. <br /> Generatofs!Ofleroes Print yped Name S:gnatu Ninth Day/ Year <br /> t 1 fA: <br /> _r 1fi.IntemationalShlwente d <br /> F- ❑ImpcA to'J.S. ❑Fort from U.S. Port of en7ynexi: <br /> z Transportersignalure:for exports only': Date leaving U.S.: <br /> L= 17.TransporlwAduvwledgment of Recelpt of Materials <br /> Trarsporte•1=A kdlTyped Name Signature f Month Day Year <br /> 0 : 1e' CLOUD L11-1– Z <br /> a <br /> rn Dayl <br /> Z Transportcr2PrintcdlTypodName SignatureMonth- f �- Y <br /> 1. ii".. <br /> 18.Discrepancy ! <br /> 16a.Discrepancy Indicalion Space ❑ Quantity ❑Type Full thou <br /> ❑Residue ❑Partial Rejection ❑ Reje <br /> [Ularifesl Reference Number. <br /> 18b.AtlernateFadlitylo,Generetor) U.S.EPA ID Number <br /> J_ <br /> �..5 <br /> u Fadrtys Phone: <br /> CS 18e.Signal ireol'ARe-nate Fadfiy(or Gen-mrator] Month Day Yez <br /> Q <br /> 7,5 <br /> z <br /> 19 Hazardous Waste.Report f lanagemeit Wthod Codes J.e.,codes far hazardous waste 1reatrr,en1,disposal.art recycling systems) <br /> 1 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Cartificarron of receipt of hazardous rna:erials covered ky the man fP Pxrs.nl zc rxieo in ttern 18a i <br /> 1,AeP irled'Typed NameSignature �/ Month Day Yea <br /> Ir / - <br /> 1'- %YU _ <br /> EPA FDrm8700.22(Rey 3-05) Previous edidonsan-obsofete. ESIGNATED FACILITYYO ENthk( <br /> r <br /> 1- <br />