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Please prink or the.(Forrriilesigryed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-D036 <br /> 1.Geremor ID Number 2.Page I of 3.Emergency Response Phone 4.MariffesitTracking Number <br /> 1 rl 1 c 1 '. <br /> WASTE MANIFEST I .. I .. '.- 1 014891372 JJK <br /> 5.Generators Name and Maillong Address Generators Si Addrepe(Ifdifferent then mailing address) <br /> Cc, <br /> CAMSM&S Phone: <br /> S.Transporter 1 Company Name U.S.EPA 10 Number <br /> En ,rorjr,lerjraj R '1 0 fl 2 1 -5 <br /> 7.Transporter 2 Company Name U.-5!EPAlDNurnbe0 <br /> I �*IPSMITICNIM�-iVitcIt", U.S.EPA 10 Number <br /> r t o n <br /> Faciffy's Phone: <br /> 9, 9b.U.S.DOT Description(iroluding Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if my)) No. Type Quantity wt./vol. <br /> rcif-aaining 43rm-ablP limuid.r..O.S.ilasrdtese)1..4.1, <br /> 'byq <br /> 4 <br /> FILTER RECYCLING SERVICES'RIALTO FAC <br /> IL- RA <br /> 14.Spedal HW ng Instructions and ! Uel-r-ea ffw—vm's- 1 i. <br /> 1hW*11 7'1'97krj R ' FFRMITR"`T <br /> AND WILL:CCEPT; THIS WASTE AS S111PRED <br /> 15. GENERATORWOFFEROVS CERTIFICATION: I hereby declare that it*contents of this consignment are fully and accurately described above by the proper Shkolpfirig more,and M classhled,packaged <br /> marked and labeled/placarded,and we in so rospects in proper conditbr,for transport w=ncing to applicable intemaho"and national goveTmental regulations.If export shipment and I am the Primary <br /> Exporter.I car*that the contents of tMs consignment conficnim to On Wore of the attached EPA Acknowedgimers of Consent. <br /> im"tbatihawssle mirronzatibm stakedWHAieffied in 40 CFR 262.27(a)(if I am a large quantity generat000r(b)(it I am a"I ci;ttygemamt#true. <br /> Generatoesl0flerm's Month Day year <br /> X It t- IL <br /> 16.InsamationaKiltipments <br /> ENW to U.S. El Export from US., Port of ontryindt <br /> Transporter signature(for exports only): Date eming U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Trawder I PrintedfTyped Name i Signature LbIlt Day Year <br /> 0 1 f /I i� .I � , <br /> 0 �* 4- " I a ILI I IL <br /> m Transpaterziermisolypeo Nam t Signature f Month Day Year <br /> ♦ 18 Discrepawy <br /> 18a, cy Indica n SpacIlVa ype. <br /> "'N'n4'ej f-P�AYAM&-bl-p' '4 an a �Kparfisl 4"e4;o ull Rejecuo, <br /> 71 DR- <br /> - Man fast Reference Number FIN E 4 <br /> 16b.AKemzdeFad1ty((13�er;1kor) F, —,10.M04flwftr <br /> Facifitys Phone: • <br /> 18c.Signature of Aftenlahs Faclor(Or Liansoaloq Month Day Year <br /> 19.Hazardous Wage Report Management Method Codes(i.e.,codes for hazardous waste treafinK disposal and recyding systems) <br /> 1. 2. 3. 14, <br /> +�-o i o 1 1 <br /> 20.Designated Facility Omer or Opera!g,Certification at receipt of hazardous materials covered by the manifest=t as noted in 1 <br /> I'mUNITtypeo N Signa eta" o ay Yeas <br /> EPA Form 8700-22(Rev.3-05) PreNous ecifflons'lareobackete. DESIGNATED FACILITY TO GENERATOR <br />