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O6/07/2011 11:12 FA% 7639726789 C�0005/0006 <br /> . e � � ' <br /> Manifest# <br /> �a� <br /> SKB Rosemount Industrial Waste Facility 1 S 3 0 6 7 <br /> 1.Generatoc's US EPA m No.(if any) 2 Page 1 o�F page(s) <br /> ' ' • E�vtvyioXS�N <br /> 3.Generator's Name and Facility Addresa /► Mailirtg Address ` 1 <br /> ��/f OT� �'f0 ' �it�r �oaST/�fl��� <br /> CvAS�i�vs.�Ie �a"QI,!'� 3�1�f.,F. <br /> 4.Generator's Phone QQ r �/ Fax <br /> 5.Transporter 1 Company Name <br /> l� ���V7/D�S Phone: ;�� � ��3 <br /> 8.Trensporter 2 Company Name <br /> Phone: <br /> �.Designated Faclliy Name and Site Address Sgg Rosemount Industrial Waste Facility <br /> 13425 Courthouse Blvd. <br /> Rosemount, MN 55068 651-438-1500 <br /> 8 . atemen enerator ontractor BB, Responsible Agency MPCA <br /> Address ,��o�N �i Address 520 LAFAYETT'E ROAD NORTH <br /> G City,State,Zlp .f'f�//� City,State,Zlp ST.PAUL,MN 55155 <br /> E <br /> N Operetor's Phone��689'Q90D (,� �j'�—f�/,� 651-296-7897 <br /> R SC. U.S.DOT Description(including Proper Slupping Narne) 9. CoMslners 1 p. 11, 12, <br /> A Total Unft Waste Profile <br /> � . � OS N�. Type Quarriity WWoI Shset# <br /> R e. <br /> ASBESTOS,9,NA 2212,111 �� g f /� /,���� <br /> �(7 <br /> b. <br /> 13. Additionel DesCriptlons for Meteriale Listed Above(Indit�te waae sveam Approvel r bebw) 14. 5peciel Hendling PtoCedures for Westes Lieted Above . <br /> a.MI <br /> b.MI �� 'D��id ��C <br /> 18:Special Handling Instructions and Addlltfonal IMormatlon EMERGENCY CONTACT, SKB U�e Only <br /> �D�� Load# <br /> Scele Wt. <br /> • Tons/Yds. <br /> 16.GENERATOR/ABATEMENT CONTRACTOR'S CERTIFICATION: I hereby dedare that tlte contents of this consignment ere fully and accurately <br /> described above by proper shippfng name and are classified,pecked,marked,and Iabeled,and are in all respects in proper condition for Vansport <br /> � by highway.aocwding to applicabla irrtemational and natbnal govemmeM regulatio�s. <br /> PriMed/Typed Name SignaWr ' Month Day Year <br /> � l�/ . G Y� D l � <br /> R 17.Transporter 1 Adcnowledged of Reoeipt o1 Materials <br /> A Pdnted/Typed Name Slgnatur ' Month Day a� <br /> s a � � �- s— <br /> 0 18.Transported 2 Acknowledgement of Receipt of Materfals <br /> R <br /> E Printed/Typed Name Signature -Month Day Year <br /> R <br /> 18.Discrepancy Indica�on Space <br /> F <br /> A ' �1 <br /> C �/ <br /> 1 <br /> L <br /> I <br /> Y20.Facility Owner or Operator: CertiNcatlon of receipt oi no -hazardous matedals cover this Manifest except as noted in Item 19, <br /> Primed/Typad Name Signature a �� <br /> White-Retum to Ge erat r Green-Facility Copy <br /> Canary-TranspoRer#2 Pink Transport r#1 Goldenrod-Generator Copy . <br />