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FROM (MON>OUL 8 2012 lEt:36lST. 18:32/No, 7679684107 P 7 <br /> r <br /> Please print or, pe.(Form designed for use on elite(12-pilch)typewriter. <br /> FiGen for ID Ntxnber ) form Approved.C}MB No.2050-0039 <br /> UNIFORM HAZARDOUS 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking NumberWASTE MANIFEST L D 5D "S-977-SM G B F <br /> S-Generator s Name and Mailing Address Z 1o�L'-1I1 G� J 1 I'j Generators Site Address(if different than malting address) <br /> CA <br /> GeneraWs Phone: j e. <br /> 6.Transportan 1.Company Name U <br /> CRU .Cydlc is Inc2 5' <br /> 7.Transporter 2 Company Name <br /> a$.EKIPIN. z <br /> x. . <br /> 3 Desi naled Facility Name and Site Address U.S.EPA 1D Number <br /> 6A Recyclinq Service Inc <br /> 101 Hasten Or <br /> Woodville, NIA 540M 801G-20-2 04 <br /> Facility's Phone: <br /> 9a 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)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> 21 <br /> Qo Non-RCRA Hazardous Waste Solid Z DI <br /> M P <br /> W 2 <br /> LU <br /> THIS COPY IS YOUF1 <br /> 3. <br /> OF RECYCLING <br /> 4. BY.. .. ...........[?ATE.�� , . !.a <br /> al di Inspd.ns and ly�itional lnformatf <br /> ar eOilye naM1Q ar. 9,1 -04LY kOSORSENT E.RO.-9.11 #11711 <br /> 15. GENERATOR'SIOFPEROR'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 labeledlplacarded,and are in all respects in proper condition for transport according to applicable intematignaland national governmental regulations.If export shlpment and I am the Primary <br /> Exporter,I certify that the contents of this oonsigrmenl conform to the terms of the attached EPAAcknowledgm eoi Consent. r <br /> I certify tha:the waste min'nnizatlon statement Identified in 40 CFR 262.27(a)(if I am a large quantity generavor(b)(if I am a small quantity generator)is t ~7 <br /> Generatou's/Ofterols Printecirrypedpame Signa,re Month Day./ Year <br /> r � u <br /> J 116.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> LU 17.Transporter AcknoWedgment of Receipt of Materials <br /> Transpo cirryped Name Si re Month Day Year <br /> IPPrinte� �� ! (,� ���' �'�1?1 �'� rLk '.r z { is <br /> CL <br /> rn <br /> Q Transporter 2 PdntedrTyped Name Sign Month Day Year <br /> tY <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Agemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> W 18t.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> 19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> w0 1. 2. 3 4. <br /> 20.Designated Facility Owner or Operator:Certification of receip'.of hazardous materials covered by the mani as noted 1 tem 18a <br /> dnted yped Name ignature Month Day Year <br /> J-ere rn <br /> EPA Form 8700-22(Rev.3-05) evious editions are tete. <br /> DE GNA*D FACILITY TO GENERATOR <br />