Laserfiche WebLink
r FLROM (MON)JVL 8 2012 1E3:38/ST. 16:32/No. 751 96841 0 7 P 77 <br /> Please print r type.(Form designed for use elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> 0 IFORM HAZARDOUS 11-G ra umber 2.P;7 3.Emergency Response PhoneManifest Tracking Number <br /> 1001315,892 <br /> WASTE MANIFEST _ 559-977-6282G B F <br /> 5.Generator's Name and Mailing Address rf1r a 0-i: /' Generators Site Address(d d flerenfthan mailing address) <br /> Generators Phos: <br /> 6.7raospoder 1 Company Name U0029161 <br /> CRI Recycling Service Inc <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> 8.CF41 Recvallinp ated Facility Name aSMoe Inc nd Site ss us.EPA ID Number <br /> 101 Hagen Or WIR000029761 <br /> Wwdville, WI 54028 OW-241-2W4 <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT DescAption(including Proper Shipping Name,Hazard Class,)D Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group till any)) <br /> No. Type Quantity Wt.Nd. 13.Waste Codes <br /> 1 3 <br /> o Non-RC.RA Hazardous Waste Solid DM p <br /> a ' <br /> w2 <br /> - Icy Y <br /> �'iFI � ou <br /> .�� <br /> 3. � «, <br /> 8Y L AVG <br /> 4-10111 ww <br /> T ar <br /> E <br /> Y. <br /> 1 rVADI IDMI Von VOWA�'Wtyewear. 9.1 -OILY ABSORBENT E.R.G.-91A #'171 <br /> 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, <br /> marked and labele4lacarded,and are in all respects in proper condition for transport according to applim*i� temabonal and national governmental regulations.It export shipment and i am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terns of the attached EPA Adknowl"ment of Consent. <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(a)(if t am a large quantity gegerator)cc(o)(ill am a smai4quantity.ganer Wr)is hue. <br /> Generator's1011eror'sPnatedlTyped Name _ Si 're \ Month Day Year <br /> --r 16 lnbirFe Tonal Shipments <br /> F-- ❑Import to U.S. ❑Export from U.S. Port of an trylexh: <br /> Z Transporter signature(for exports only): Data leaving U.S: <br /> LX 17.transpodKAcknowledgment of Receipt of Materials <br /> Transp iter 1 PhrnedlTyped Namer ' Sign e d, t,• Month Day Year <br /> A: <br /> X¢ Transporter2 PrintedlTyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> aa.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejecllon ! ❑Full Rejection <br /> Man'dest Reference Number. <br /> 181h.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL. Facility's Phone: <br /> W 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> Q , <br /> z <br /> h19.Hazardous Waste Report Management Met cid Codes(i.e.,codes for hazardous waste treatment,.disposal,and recycling systems) <br /> wxT <br /> 1 2. 3. 4- _ <br /> 20.Designated Facility Owner or Operator.Certlficatign of recsipl gf hazardous materials covered by the ei¢ept as ruled in Nem <br /> Prin�ped Name `4 Signature <- - month Day Year <br /> 14 <br /> EPA Form 8700-22(Rev-3- ) Previous editions are obsolete. <br /> ` DESIGNATED FACILfWGENERATOR <br />