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t.Generator's US EPA 10 No,(I/anyJ 2.Page 1 ot page(s) j
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3.Generalor's Nam and F�ciliry Addreas �'h h d� Mailing Address
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�.Genera�or's nono
5.T�ensporter� Company Name
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8.Tr�nspo►ter 2 Comp�ny Name,
phone; j
7.pesigna�led Facility Name end Si1e Address SKB .�iosemount Industria] Waste Facility
13425 Caurtllouse B]vd.
Rosemou.nt, MN 068 651-438-1500
8A. Abg�emenUGenerator Conlractor BB. Raspaneib�e Agency MPCA
Address �,�.� 3� '� �'j" !Ada1'6sB 'S20 LA�r1'rE?TE ROf�D NORTFi
cuy,State,�Ip S7 PAUL,MN 55�55 �
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N Qpera1or's Phone No. Z U j _ 7/ 851-296-7997
R 8C. U.S.DOT OesCri�llOn(IncludJng Proper Shipping NnmeJ 9, Coniainers 10. 11. tE.
n To1al Unit Waste Prefila
7 No. Type Ouamlty WWoI Sheet�'
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13. Addltionai Deserlptlons for Mate�lals LisfeC Above(ind�o wasro siroom nppro�arm n�,iow) 14- Speclai Hendltny Procedures(ar Wastes Listee Above
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15�SDeclal Mandling Ins rucllons snd Acl Ilional In►ormatlon ' • 5K9 Uao Onfy �
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16.GEN�RATORlaBATEb1EMT CQNTRACT4R'S CERTIFICATION: I herepy de�l�re Ihet the conlenls o(1�Is consignment are fully and accuralely
described ebove by proper shipping namo and are clasallled,pocked,m2rked, 9nd labeled,and are in all reBpeclS in propel condition(or transpon '
by highway accordirig tn applicab[�inlernatianal snd natlonal g�vernmenl repu liona,
I PrintedlTyped Na p 5ignaturo Monih Day Year ,
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r 17.Transponer�Acknowledged al Rec of Malerials
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A Printed/fyped Neme S�gnalure Mont� Oay Year �
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0 1 e.T►'anspo►ted 2 Acknowledflement of Receipt ot Mate�ials .
a P►inted/Typed Nam� Slg�ature Month Oay Year
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19.dlscrepancy indlcaiion Spece •
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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.
Prinzea/Typed Name Slgn¢�Iuro Month ay Year