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FORM �S I Generahx Numoer i (860)424-9300 U1 b ( U1 .513 JJr% <br /> WASTE MANIFEST <br /> CAI Q t Cl Ig 81 <br /> Generator's Site Address(it difTerent than marling addrm) <br /> R7 mc <br /> MCI TURNPIKE RD <br /> STOWON CA ass <br />�retor'sPnone: 209 475.8181 <br /> tt U.S.EPA ID Number <br />,,j;&6�IIY YIR014MENTAL SERVICES 277036 <br /> U.S.EPA ID Number <br /> a. 2 n Name CAR000175422 <br /> 'LD IRE RECOVERY SYSTEM INC. <br /> a U.S.EPA ID Number <br /> C <br /> E13THSTAZ 8 AZR040525924 <br /> "AA,ry's Phone: (928)344-9828 <br /> 10.Containers 11.TotalT12.Unit13.Waste Codes <br /> U.S-DOT Description(including Proper Shipping Name,Hazard Class,ID Number, QuantityNol. <br /> t and Paddrg Group(if any)) No. Type <br /> t.'r,;:FPZCRAHAZARD0JS'e.5 TE SOLID(PAPER FILTERS) 352 <br /> D M •"C � P <br /> 2. <br /> 3. <br /> 4, <br /> Special Handling Instructions and Additional Information <br /> EFAERGEN,ZY 001141"AiCT 'CHEMTREC 1-800.424-9304 WOES TERMINAL CERES CS NAERG#981 :171 *PROFILE#t 981 : <br /> 16211323?`PS-VAL691 PAPER FILTERS * * IATE, K E 1 <br /> APPF91,RI �U11MENT <br /> ' +y` <br /> ,.ya -_\x�ix. •`.?�-,�;`A�, c�-] f,a,;.�_ - v� _J�o OIa.,.. <br /> GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if 1 am a large quantity generator)or(b)(if I am a small quantity ge "tor)is true. <br /> neratorsl0fieror A P" Raped Narge Signature • — Month Day Year <br /> y`'! (J ,✓ <br /> International Sh is <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit <br /> ansporter signature(for exports only): Date leaving U.S.: <br /> Transporter Acknowledgment of Receipt of Materials <br /> ansporter 1 Printed(Typed Name Signature Month Day Year <br /> kp/ 13 <br />'ansporter 2 Printed/Typed Name Sigrlaiu Month Day Year <br /> k. e' tom. <br /> 8.Discrepancy � <br /> Ba Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 8b.Alternate Facility(or Generator) Manifest Reference Number. U.S.EPA ID Number <br /> aality's Phone: <br /> Bc.Signature of Alternate Facility(or Generator) <br /> Month Day Year <br /> 9 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. 4. <br /> 0 Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 19a <br />'rintedfTyped Nam q Signature j <br /> ! Month Day Year <br /> r'orm 8700-22 Rev.3-0 ) Previous editions are obsolete. <br /> ESIGNATED FACILITY TO GENERATOR <br />