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Please printortype.(Form designed for use on elite(12-pitch)typewriter) Form Approved.DIVIB No.2050-0039 <br /> 1 <br /> . <br /> UNIFORM HAZARDOUS <br /> . 2,11.Generator ID Number Page I of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> 013482960 JJK <br /> WASTE MANIFEST I L <br /> TGenerators Name and Mailing Address Generator's Site Address(If different than mailing address) <br /> Cookc-"dfisilm of Tract c-TO a1r,f:)j <br /> RP&ICul;j-'-ftV 'A 9*53LO. -r' v.304 <br /> Generator's Phone: <br /> B.Transporter I Company Name U.S.EPA ID Number <br /> F-ri-,--irvirt-tental Lfoclis-Zir-4. - '1 F f! ?% 'D �'.; ' �- i. .I - <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Nam and SiteAddress U.S.EPA ID Number <br /> Rae,, Seromas.Inc- <br /> 180 IVA.; kioilrr-AkW$-,r.?.je <br /> ;-& C <br /> n.-4 <br /> Facllitys Phone: gf)Q 421.2j)j: 4 .3 �k <br /> 98. 915.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(If any)) No. Type Quantity Altivol. <br /> Solid i6yropy Pair"!Cars,, <br /> Z 2. <br /> UJI <br /> FILTER RECYCLING V1001 RIALTO FACILITYEPA <br /> F- MIDIAPP101 P. <br /> R <br /> AND WILL <br /> % <br /> 4. <br /> 14.Spedal Handling Instructions and Additional Informationwra C-2! 1,1-1-5 2 2 0 i <br /> 1.1 4:'5 604,! one or more of the material listed on this manifest qjay-' <br /> be recycled as alternative daily cover(ADC), or other <br /> method which uses the material in or on the land <br /> 15. GENER4TOR131OFFEROWS 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 labelecl/pecarded,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 Prirnary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmentcf Consent. <br /> I certify that the waste minlrnization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)Cif I am a small quantity generator)is true. <br /> GanDratoestOfferoes Printed/Typed Name Signature Mordh Day Year <br /> 16.International Shipments <br /> El import to U.S. El Export from U.S. Port of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W17 Transporter Acknowledgment of Recelpt of Materials <br /> Tran porter 1 PrInted/Typed Name Signature Month Day Year <br /> 0 r .1 <br /> .Z Transporter 2 P d Name Signature Month Day Ygh r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Spam El Quantity Type Residue Partial Rejection Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facility's Phone: <br /> in [ <br /> LLj 18c.Signature of Alternate Fac lily(or Generator) Month—Day' Year <br /> !R I2E I I <br /> 0 <br /> rn 19-Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 01 2, T 4. <br /> \- <br /> . A-�kt I I <br /> 20.Designated Facility Owner or Operator:Fettification of receipt of hazardous materials covered by the manffe7ft-xcept as noted In qm <br /> IP A, A <br /> Printed/Typed Name Sig r Month Day Year <br /> ail I <br /> EPA Form 8700-22(Rev.3-05) Previous editions A ollsolete. DESIGNATED FACILITY TO GENERATOR <br />