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,y a Please print r type.(Form designed for use X.elite 02-pitch)typewriter.) Form Approved.OMB No.2050-0039 (FORM HAZARDOUS 1.Gen ratA umber 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number EST � WASTE MANIFW}.S ))�Oob I `7 559-977-62 82 G B F 5. e Genrator's Name and Mailing Address ! r "�C , (+�{� Generator's Site Address(if different than mailing address) . dA .^.-fir• f Generator's Phone: 35 / Z, 6.Transporter 1 Company Name U CRI Recycling Sel'vice Inc , 61 7.Transporter 2 Company Name U.S.EPA ID Number 8.Desi nated Facility Name and Site Address U.S.EPA ID Number CRI Recvcl-gnq Service Inc R 7 61 101 Hagen Or Woodville, iNl 54D28 8W-241 -200A Facility's Phone: 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Pactdfig Group(if any)) No. Type Quantity Wt.Nol. 1. 223 Non-RGR, I-aza rbcs Waste Solid � LM P W 2. 3. CZ) E, 4. //? ^ i' o- 14. ecial dfl Ins uctions d iGonal Inform a car rro�ec�>ve ing ar a Eyewear. 9.'I C�1L' ABSORBENT 1= R.G. #111 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicab�wiritemational and national.govemmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknow�figment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or O(if.l am a smallquantity.gener tor)is true. GeneratorslOfferor Printed/Typed Name Signature % Month Day Year r---r 16International Shipments Ex ort from U.S. Port of ent )exit: ❑Import to U.S. ❑ p ry Transporter signature(for exports only): Date leaving U.S.: W 17.4YansporterAcknowledgment of Receipt of Materials /, Transp iter 1 Ph.ntedlTyped Name Sign a/ y KL p , Month Day Year (14Lj p vi. 3 QTransporter 2 Printed/Typed Name Signature Month Day Year H 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type y El Residue ❑Partial Rejection !! El Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number V .r Facility's Phone: W 18c.Signature of Altemate Facility(or Generator) Month Day Year Q1Z 05 19.Hazardous Waste Report Management Met odCodes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) C 1 " 2. 3. 4. . � °to 20.Designated Facility Owner or Operator:Certificatign of receipt of hazardous materials covered by the ma ifesfexcept as noted in Item a 1 cti ;. PrintedlTyped Name �`Signature Month Day Year EPA Form 8700-22(Rev.3- ) Previous editions are obsolete. DESIGNATED FACILI1"YTO GENERATOR Ate.