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Please paint or type.(Form designed for use on elite(12-pitch)rypewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.GenVL <br /> tor ID Number q 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST � U `j 1 559-9]7-6282 001335137n, G B F <br /> 5.Generator's Name and Mailing Address rt} �}ti� ) fv sJ <br /> s ' I Generators Site Address(if different than mailing address) <br /> r 1 f✓ f✓E4 <br /> CA <br /> Generator's Phone: ' ) (y <br /> 6.Transporter lrcompany Name U r <br /> CRI-Recycling ,.Servoice Inc <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.6e�snatedFaly;n a�nd�Site±did est U.S.EPA ID Number <br /> 7 1 <br /> 101 Haaen Dr <br /> Woodville, 'Will 54 ili-2WA <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No, Tye Quantity Wt.Nol. 13.Waste Codes <br /> 1. <br /> o Non-RCRA l-lazardims Waste Solid DIM P 23 - -- <br /> �- _3 <br /> z 2. <br /> W <br /> THIS COPY is T oUp <br /> 3. CERTIFICATE <br /> OF RECYCLING <br /> a. BY.. .., DATE .... <br /> 1 e i I dli Ins ctions d itional Inform i <br /> tr ir�`�ec eve Geo ianq� a+� f-vewear. S 1 -- OILY ABSORBENT F.R.G. 9.1 171 <br /> 15. GENERATOR'S/OFFEROR'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, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intematig2a1and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgm t'df Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generatA or(b)(if I am a small quantity generator)is t j <br /> Generator's/Offers Printed/Typed Name Sre ignalUMonth Day Year <br /> � ��:=. 1..- �`_..,��-"' . <br /> 16.Inlemational Shipments <br /> Z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials 'a <br /> Transport Priinnt-eedrryped Name Si re r} <br /> Transport <br /> Month Day Year <br /> a �Vy� <br /> QTransporter 2 Printed/Typed Name Sign re Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantityyp <br /> ❑Type ❑Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Atemate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> LL Facility's Phone: <br /> LU 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifes as nde i tem 18a <br /> Printedffyped Name ignature Month Day Year <br /> �erer� <br /> EPA Form 8700-22(Rev.3-05) IYevicius editions are allsolete. <br /> DE PIA D FACILITY <br /> TO GENERATOR <br />