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Please print or type. Form Approved.{1MB Na.2050 00? <br /> UNIFORM HAZARDOUS 1'Generator IO Number 2.Psgs,l.of 3.Emergency Response Phone 14.M sstTra f m r <br /> WASTE MANIFEST C�A L � ��� °�� � � �C19,-�✓t-�`�� (.� <br /> 5.Generator's Name and Mailing Address <br /> !a")7'A!: gie V e si 36Jct 4-e r Generator's Site Address(d different than mailing address) <br /> WOVMAL SCKYICE P.,Fr-1yCk t4/C INC <br /> �3IDD S Ct- D012A30 5 T <br /> 6,Transporter 1.Company Name a e U.S.EPA ID.Number <br /> 1 s "V1'AC0fA1 I,`Na4L SOL e,4'fiAA/S C �' U ! d <br /> 7.Transportar 2 Company Name <br /> U S EPAID-Number, <br /> 11 <br /> 6.Des gnated Facility Name add Site Address U.S.EPA 10 Number <br /> e. a:SB y I IOWA 7-v1V IN14 <br /> 46 <br /> 30 PV <br /> G- 4 , ,� 101813 41>029 019 <br /> FsciliVs Phone: y' <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name.Hazard Class,ID Number, 10.Coirtainsrs o <br /> HM. and Packirxd Grcip(if any)) 11.Toth 12:Unit <br /> No. Type Quan* WtJVa, 13,Waste Codes <br /> �r /� p� ]',rye <br /> /7AIAR�a*9S 1>Zdd�ajaa 0411/u�$JC} <br /> z 2 <br /> cls#�sr fa�r <br /> W <br /> DISPOSAL 11t.11AIIN Nr'Cit <br /> .PERMSTS CRANTE D f`,>; t. t t tt'a C,tiC(.tiT}`i�3iflt TOtii!}II , <br /> r. <br /> "RIM-13ITMD"'eff—I- vRDANCG We RiE PRa"LSlatiS <br /> PPMERAL <br /> L` 1475 •. CAa <br /> . 1'FRSf7i'S,"CU'.tCYF_Fr .1,3 .. >?.ix r1 7?r u''S7F HAS SEE HANKY, <br /> 14,SpeOial Handling lost uc6ons and/A f-itgonai Informal on gg,��j�! <br /> 15. GENERATOR'SIOFFEROR'SCERTIFICATION:Iherby dederethat thecontents of this consignment ere fully and 8W=WnMtety described above b the proper shipping marked and labeladfp,acardad,and are in all respect in Y p Pe naive,srd aredassiK packagsd; <br /> proper condition on for.transport accord ng to applicable international and national governmental regulations.it export shlpmant and I am the Primary <br /> Exporter,I cert ty that U>s contents of the consignment cprifotm tit tha terms of the attached EPAAct nowledgmentot Consank ' <br /> I c@r*that the waste minimtxation statement identified in 40 CFR 262 27(8)(d I am a large,quamity generamrpor(b)(di am a amaN quantity generator)is true. <br /> Generatoestoffemr's PrintedlTyped Name <br /> S'gnature Year <br /> 16.international Shipmentr ' <br /> i— import to U.S. ❑Export from U.S, Pod of eniry}ex3b i <br /> Transporter signature(for.expdRs 0nly): — <br /> W 17,TransprAcknowlWgm&nt of ReWpt of Material Data kawng <br /> arta <br /> Transporter 1 Printedffyped Hama <br /> Signatuna' <br /> rter2PrintedR Monte <br /> yped Norms <br /> Sgt ". Month Ds! Year <br /> 4' <br /> 16.Discrepancy `— {hp <br /> 16a.Discrepancy Ind cation Space ❑ Ouagt ty F]Type <br /> Residue Partial Ref sction O FuiB Re}edtion <br /> �- =` Manifest Relerence Number. <br /> ti 18b.ANemateFacirdy(or Generamr) <br /> c .,«RF _ U.S.EPA 10 Number <br /> ri Fad3itysPhone: <br /> w <br /> I .Sgnature otAtten ate Facility(w Generator) <br /> Month Day_ .Year <br />' 19.Hazardous Waste a Ma i. <br />' 1 <br /> pot wgement Method Codes(i,e.,codes for hazardous waste tre irfeni,dspnsai,and rscyctlrxg systems) <br /> 3 <br /> 20.Des gn ed F or Operator: of receipt heiaid <br /> PriniadlT a a(ertais covered by the ritaru(est ex x;pt as rwted to Item lea <br /> Signature <br /> ' <br />, (y `` m )�v a , <br /> EPA Farm 5700- (Rev,12-17) Previous edillare obsol8 t <br /> t4E51t�P1ATED F',4CIL1TYTt?GENERA7� <br />