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Jun 28 11 03:22p Dawn Wickman <br />E <br />Pleaseprintor type. (Form designed for use or. elite (12 -pitch.) typewriter.) <br />715-698-3485 <br />1b <br />p.2 <br />Form Approved. OMB W 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05.) Previous editions are obsolete. DESIMATED FACILITY TC) GENER ATO. <br />'IjNIF0qM -HAZARDOLJi� <br />1 <br />1. Generator !D Number <br />of <br />a. Emergency Response Phone <br />Mainiterst Tracking Number <br />11- 7 <br />T' <br />WASTE MANIFEST <br />7 <br />0 JJK <br />5. Generator's Name and MailiD3 Address Generator's Site Address (il, different than mailing address) <br />- <br />—3 <br />Generator's Phone: <br />6. Transporter 1 U.S. EPA ID Numbe! <br />T.'TranspoWz2_QqaV.zV.Nam U.S. EPA 10 Number <br />8. Desigrated FacilRy Name and Site Address U.S. EPA ID Number <br />Faclity1s <br />9, <br />9b. U -S. DOT D6� �pWn (r��ing Rtper Shipping hlarne� Hazard Class, ID Warber, <br />10. Containers <br />11. TOW <br />a2. Uri <br />13. Waste Codes <br />Type <br />HM <br />and Packng Group (it any)) <br />Quantity <br />"Jvol. <br />3ro <br />twit <br />2. <br />COPY IS YOUR <br />,',`. <br />�tscycuw <br />-7 j,Ieoa <br />'ed <br />1 -119 d <br />114. Special Handling Instnxtiorts; and Additional Information <br />0 <br />15. GENERATOR'SFDFFEROR'SCERTIFICATION: I hereby declare that the contents of this consignment are fully and acwratett described above by the proper shipping name, and are classified, packaged, <br />marked and labelediplacarded, and are in all respects in proper conditicni for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />ExportaL I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgrnwl of Ccnsent. <br />I certify that the waste mirimization statement identified in 40 CFR 262.27(a) (if I am a large quantty generator) or (b) (d I am a snell quantity generator) is true. <br />Generato ar�4�rrtedlTypad Na.w Month Day Year <br />estaff <br />ji <br />--j <br />1fi. InternallicTlal Shilipraefitti <br />P <br />ElExport from U.S.ofeWe)dt <br />131.pt'us. ❑ <br />Transporter signature (for oxparts; ony): Date leaving U.S.: <br />LU <br />17. Transporter Ackowledgment of Receipt of Materials IAf <br />Transporter 1 Ptirrtedffypad Name Stnature Mon Day Y <br />J <br />10 d Name Si Mob-th Day Year <br />Signature Twns,��_;1n <br />A' <br />18. Discrepancy <br />18a. Discrepancy Indication Space 11 Q'arrfity D Type F-1 Residje Ell Partial RejectionV EIF.ii R*ctir, <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />Fa--tlkYs PFone: <br />r3 <br />tu <br />I&r.SigrwWreo[AkemateF3cl4(orC-.Lwrato,,) <br />Month Day Year <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste lireatmant, disposal, aDJ recycling systems) <br />-T <br />C3 <br />- <br />4. <br />20. Designated Facility Owner or Operator: Ccrtilication of recei:A of hazardous materials covered by the mar-irpstexcfA as noted in Item 16 <br />PrinWdffypeJ Name Signature Monti Day Year <br />EPA Form 8700-22 (Rev. 3-05.) Previous editions are obsolete. DESIMATED FACILITY TC) GENER ATO. <br />