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07i2ai2010 07:48 DMD SERVICES LLC � 9522494616 N0.043 D02 <br /> i <br /> NAan(fest� <br /> � SKB Rosemount Ir�dustrial Waste Facility � � g � � � <br /> rrrvi�aunere��c <br /> t.Generator's US EPA 10 No,(I/anyJ 2.Page 1 ot page(s) j <br /> � . � • � . . �, lo "�!I �i � <br /> 3.Generalor's Nam and F�ciliry Addreas �'h h d� Mailing Address <br /> �� ��� <br /> .,�7a Y 1��� �86a�Xr�� Fax <br /> �.Genera�or's nono <br /> 5.T�ensporter� Company Name <br /> �,� Pnane; 9 — Z. � <br /> 8.Tr�nspo►ter 2 Comp�ny Name, <br /> phone; j <br /> 7.pesigna�led Facility Name end Si1e Address SKB .�iosemount Industria] Waste Facility <br /> 13425 Caurtllouse B]vd. <br /> Rosemou.nt, MN 068 651-438-1500 <br /> 8A. Abg�emenUGenerator Conlractor BB. Raspaneib�e Agency MPCA <br /> Address �,�.� 3� '� �'j" !Ada1'6sB 'S20 LA�r1'rE?TE ROf�D NORTFi <br /> cuy,State,�Ip S7 PAUL,MN 55�55 � <br /> p Cily.State,Zip ` �,..�, � <br /> E <br /> N Qpera1or's Phone No. Z U j _ 7/ 851-296-7997 <br /> R 8C. U.S.DOT OesCri�llOn(IncludJng Proper Shipping NnmeJ 9, Coniainers 10. 11. tE. <br /> n To1al Unit Waste Prefila <br /> 7 No. Type Ouamlty WWoI Sheet�' <br /> 0 ' <br /> � a. �(� � <br /> ASBESTOS,9,FVA 2212,111 <br /> DM D �?' � <br /> b. � <br /> � <br /> � <br /> 13. Addltionai Deserlptlons for Mate�lals LisfeC Above(ind�o wasro siroom nppro�arm n�,iow) 14- Speclai Hendltny Procedures(ar Wastes Listee Above <br /> a.MI <br /> b.MI � <br /> , � , <br /> 15�SDeclal Mandling Ins rucllons snd Acl Ilional In►ormatlon ' • 5K9 Uao Onfy � <br /> Load# <br /> s�aia wi, <br /> TonslYds. <br /> i <br /> 16.GEN�RATORlaBATEb1EMT CQNTRACT4R'S CERTIFICATION: I herepy de�l�re Ihet the conlenls o(1�Is consignment are fully and accuralely <br /> described ebove by proper shipping namo and are clasallled,pocked,m2rked, 9nd labeled,and are in all reBpeclS in propel condition(or transpon ' <br /> by highway accordirig tn applicab[�inlernatianal snd natlonal g�vernmenl repu liona, <br /> I PrintedlTyped Na p 5ignaturo Monih Day Year , <br /> r �� D � o D� i <br /> r 17.Transponer�Acknowledged al Rec of Malerials <br /> R <br /> A Printed/fyped Neme S�gnalure Mont� Oay Year � <br /> N � <br /> S ' <br /> 0 1 e.T►'anspo►ted 2 Acknowledflement of Receipt ot Mate�ials . <br /> a P►inted/Typed Nam� Slg�ature Month Oay Year <br /> E <br /> R � <br /> 19.dlscrepancy indlcaiion Spece • <br /> F <br /> A <br /> C <br /> 1 <br /> L i <br /> 1 <br /> YZ0.Fe.ciliry Owner or Oper�ror: Gertl�calion o�receipl ol non•hazafdoue m�terlals�ovafec!by thla Manitest excepi es noted i�Item 19. <br /> Prinzea/Typed Name Slgn¢�Iuro Month ay Year <br />