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Airport -- -- .__ -- 1 7r <br /> ;r___--Form designed on elite(12-pitch)typewriter.] <br /> Form Approved,OMB No.2050-0039 <br /> cAll HAZARDC)US 1•Generalor l0 umber 2.Page 1 of 3.Emergency response phone 4.Manifest Tracking Number <br /> .STE MANIFEST y ,. ,� .� ,, FLE <br /> An pw�qd;- 'iirg Address Generator's Site Address(it different than mailing address) <br /> neraWs Phone: <br /> 1"ranspvrter 1 Company Name U 5 10 Number <br /> 3� pkv UId>�'4ar1p.wnN1 fGRS 011V . <br /> Transporter 2 Company Name U.S.EPA ID Number <br /> DeSig�ated Fadlity Name and Site Address US.EPA ID Number <br /> I WW*Neill"Ve9ml <br /> 715-553-4703 <br />=acifit'y's Phone: i! <br /> 3a. 917-U.S,DOT Description(Induding Proper Shipping Name,Hazard Class,10 Number, 10,Containers 11-Total 12.Unit 13.waste Codes <br /> jM and Packing Group(if any)) Na Type Quantity Wt,Na1. <br /> 2. f <br /> I <br /> l <br /> I <br /> r <br /> 4. <br /> 14.Special Handling Instructions and Additional Information Y <br /> ve hy <br /> e proper <br /> ping name.and are <br /> 1S, GENERATOR S!0 <br /> Ft EROR'S GERTIFICATIOW hereby declare that the contents of this eansignmenl�carbleu�ntematianal and a6anai goveand accurately(lescrioed mmentahregui0tionslP#a port shipment and lam the Pnmargyed, <br /> marked and lab eled1placarded,and are in all respects in proper conditio for transport according to app <br /> Exporter,l certify that the contents of this consignment conform to the terms of the attached EPA Acknoudedgment of Consent. on ay ear <br /> I certify that the waste minimization statement identified in 40 CFR 2fi2,27ja}(if I am a large quantity generator)or(b}(if I am a small quantity generator}is true. <br /> GeneratoCsf gerors PrintedlTyped Name f <br /> ❑Exportfrom U.S. Part of entryrexit: <br /> 16,International Shipments Import to U.S. pate leavingU.S.: f <br /> � r <br /> Trans orter sl nature for ex orfs only <br /> onth ay ear <br /> W 17,Transporter Acknowledgment of Receipt of Materials ignature ° <br /> Tan otter 1 Pr ntedlTyped Name 1 ` <br /> O RSC Month Oay Ysar <br /> 13- <br /> Signature <br /> 4 Transporter 2 FrintedlTyped Name <br /> 1S.Discrepancy Q ❑Residue partial Rejection Full Rejection <br /> 180.Discrepancy Indication Space Quantity 7YPe <br /> L� <br /> Manifest Reference Number; u S EPA ID Number <br /> 18b,Alternate Facility(or Generator) <br /> U <br /> N10 ih Day Year <br /> LL <br /> Pettitt 's Phone: <br /> 0 18c,Signature of Alternate Facility kor Generator) <br /> d <br /> 19.Hazardous Wase Report Management Method Codes(i,e.,codes far hazardous waste treatment,disposal,and recycling systems � <br /> 3. <br /> 1 2. <br /> 20.Designated Facility Owner or Operator'Cerlificatian of receipt of hazardous materials covered by the mS i est ex ePt as noted In Ilam 180 <br /> month Day Year <br /> PrintedlTyped Name <br /> GE4`1ERAkT4R 51N1T1►AL COPY <br /> E=PA arre F8700-22(Rev.3-05) Previous editions are obsolete. <br />