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Please print or type.(Form designed for use on elite(12-pitch)typewriter <br /> UNIFORM HAZARDOUS 1.Generator ID Number - Form APProved OM8 W 2050-OM <br /> j. 2Pageiof 3 RasporrsePftone 4 Manifest Tracking Number r v <br /> WASTE MANIFEST atm 36 <br /> tJJK5.Generators Name and MaFn Address s '' OP <br /> 9 Generator's Site Address(dddferentthan malingaddress) <br /> NOb <br /> �. <br /> Generators Phone: . <br /> { <br /> 6.Transporter 1 Company Name U S.EPA ID Number <br /> 4E`fTt� sr�>??:'C:c57�irN s F_thy" <br /> C.`�?rQCt3r3 i <br /> 7.Transporter 2 Company Name <br /> U.S.EPA 10 Number <br /> 8.Designated Factity Name and Site Address US.EPA ID Number <br /> .�',+G?i�IILH Fa'J tfFflp.i�,sT <br /> 5S20 I•s:RRTi!4'RD w,wvs..rvsrr..:i. - <br /> Facility's Phone: 2'-SY'2r a <br /> 9a. 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11:Total 12.4 <br /> HM and Packing Group(dartyp 'No T OuanBly +p/tlr/d <br /> .43.V099 Codes <br /> yPe <br /> Z52 I t <br /> �O METAL�L FILTERS) q f <br /> W. <br /> 3 .. r on r,sli}Efr'+J t �r�3.�. c Cr4l tcc+cs <br /> �� JTl.. LLI'"r}fJ 3i-' �'a�"'4j�ii•-�wyq.�).w Y _ r-*2`2 <br /> I , <br /> J 1 <br /> ' 1 <br /> 1}PR L is wrination <br /> f�IE II'FIL`E ]952)PPXFU-4 <br /> 41 ST tr_1-'-ti?7 i " =c�-z`.?F':,nt3�ONTAL•AS RX-GST rll}1F sF.TRS <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this corsignmerd are fully and accurately desrnbed above by rhe proper shipping name,ac d are classified,packaged, <br /> marked and labeled/placarded,and are in ail respects in proper condition for transport accordng to applicable international and national governmental regulations.If export shipment and I am the Prirrory <br /> Exporter,I certify Nat the contents of this consignment conform to the terms of the attached EPAArlmowledgment of Consent. <br /> certify that the taste mirihization statement identified in 40 CFR 26227(a)(d I am a farge quantity generator)or(b)Qf m a small quantity generator)is true. <br /> t'xrieratoeVOflerors PnntedlTyped Name Signature %. I - <br /> Month Day Yew <br /> 1. 16.International SN <br /> pments <br /> r` ❑bnpat W U.S. ❑E'Ifrom U.S- Pmt of entrykik <br /> z Transporter signature(for exports only). _ Datin uft U.S.: <br /> w 17.TransporterAdmowledgmentofReceiptofMaterials ✓�; {' �� � w <br /> Transporter 1 P'�dlTyped Name r• x <br /> O ... 7 f ' MIS Day <br /> 0. <br /> z6-0 <br /> 2 Pnnted(fyped 1"; - r; <br /> �9natl+e J / �� ,.Mordti ' 'Day Year. <br /> 18:Df�reparrcy •;L:r-.i' .. - <br /> 16a.'Oacmpariy indication Space <br /> ❑ ❑Type ❑Residue ❑Partial Rejection <br /> FA R* . <br /> Manifest Reference Number, i <br /> '18b.A@emata Facility(or Generator) U.S.EPA ID Nwtber <br /> LL; Facility's Phone: <br /> I <br /> LU 16c.S gnature of Alternate Facility(or Generator) Mordh Bay -Year;'- 4 <br /> a - <br /> z .I <br /> US19.Hazardous Waste Report Management Method Codes(,e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> 3. 4 <br /> 20.Designated FaciRy owner or Operator Certificationof wiisipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> P!iotedffyped Name Signsture <br /> Month <br /> EPA Form 8700-22(Reu 3-05) Previous editions are obsolete - DESIGAIATED FACILITY TO GENERATOR <br />