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RROM (MON)JUL 8 2012 18:371ST. 16:32/No. 7519684101 p 10 <br /> Please print or rm designed for use on elito(12 pitch) peyvritet; <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS r j�{ 2.Page 1 of 3.Emergency Response Phone 4.Manfttt Tracki Number <br /> WASTE MANIFEST ��-2���FV� 5�5-977 ig 5195 3 6 G B F <br /> Generator's Site Address(if difterend than mailing address) <br /> , KLEXov <br /> STQ tlN.-CA# 1 <br /> Gf enera `' - .i <br /> acY rVjc lop <br /> 7.7 ranspaler?ifiz+nPenY Name <br /> 6. U.S.EPA Designated Facility Name and Site Address I Nu r <br /> cR( R2G>lrCl)!�a Service Inc �t�0` ���75'# <br /> 1171 Hagen Or <br /> YVoodville, VIA IOM "-2d1 <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT Desrn'pbon(Including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11-7o1aI 12.Unit <br /> HM and Pad*Group(f any)) No.- Type quantity WLNd. 13.Waste Codes <br /> o Nora-#MCRA Hazardws Waste SoldM <br /> io P23 <br /> 1 . <br /> z 2. <br /> LU <br /> 3. otp <br /> ATE <br /> RECYCLING <br /> xA'n I on �nd,4��lionallnfo � ;' <br /> ar�aMe e �lotl'N ani��°1yewear_ 9.1 -OILY ABSORBENT E.RG.-9.1 #M <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and acctrately described above by the proper shipping name,and are classified,packaged, <br /> marked and fabeled'piacarded,and are in all respects in proper condioon for transport according to applicable infemafionaland national governmental regulations.If export shipment and I am the Pritrary <br /> Exporter,I certify that the contents of this consignment conform to the terns of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator es PmtedlTy N me Signature t r Montlr pay Ye9r <br /> X _A�Q f.(' ; <br /> 16.Intemabonal Shipments <br /> ❑Import to U.S. ❑Expon from U.S. Pod of emlrylexit <br /> Transporter signature(for exports only): <br /> Date leaving U.S:: <br /> W 17.TransporterAcknowledgmenl of Receipt of Materials <br /> 0 Transporter 1 Printed�Typed Nage Signatgre �' Mo Day Years <br /> � 1 G l✓-1 t . <br /> a Transporter 2 PrintedlTyped Name Signature Month Dsy Yeerd_ <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity r_ aY ❑Type ❑Residue El Partial Rejection ❑Full n <br /> n �Gut r c i Y\. E r y UY <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> LL FacOty's Phone: <br /> w f 8c.Signature of Altemate Facility(or Generator) Montlr Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling syslems) <br /> UJ <br /> C3 11-K135 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as nded i 18a <br /> P'ted Typed Name S afore i <br /> 9n Mo ear <br /> EPA Forth 871X-22(Rev.3-05) Previous edifflare obsolete. <br /> DESKiNATED FACII JTY TO GENERATOR <br />