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Pjeasb.print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page I of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST .-. '. � .1. .1� -1 . - .�-, " �. -, . ` 481026 JJK <br /> J, I-) -wr <br /> 01' <br /> T Generators Name and Mailing Address Generator's Site Address(If different than malting address) <br /> Phone: Q <br /> Generators j te <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> o <br /> 7:Transporter 2 Company Name U.S.EPA ID Nurffber <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facflll es Phone: 06 9- <br /> ga. 9b.U.S.DOT Desorliotiorl(including Proper Stripping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Pecking Grouip(iter)) No. Type Quantity WII.Aki. 13.Waste Codes <br /> 'hIw-t-R,-.RA Hizar:k-,u:; Slid i1;ondo Dun.; <br /> Z 2. 0 C 1 t <br /> UJI <br /> FILTER RECYCLING SER EET RIALI <br /> it C A Q P 2 J,4 4P'.8 T 4 E A <br /> 3. E At'. <br /> "'PIP <br /> AND WIL A""T' <br /> 4. <br /> 14.Special Hard N Instructions and Additional Information <br /> 15. GENERATOR'SIOFFEROR'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/oacarded,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 ceffy that the contents of this consignment conform to the terms of the attached EPAAcknovAedgment of Cement. <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(If I am a small quantity generator)Is true. <br /> Gerreratots/Offeroes Printed/Typed Name Signature Month Day year <br /> o <br /> 16.Inter6alional Shipm <br /> ants F-1 Import to U.S. El E*rt from U.S. Part ai entryfexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> LO: 17.TransporterAcknowledgment of Receipt of Materials <br /> Ll <br /> � Transpo ler 1 PrInted/TypDd Name Signature Month Day Year <br /> 0 -1 <br /> Z Transporter 2 PrinledlTyped Name Signature.- Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Woq <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number . <br /> u<- <br /> Facility's Phone: <br /> LU 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> 05(D - <br /> 19.Hazardous Waste Report Management Method Codes(le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLJ 1. 2. 3. 4. <br /> I <br /> L. I I I I <br /> 20.Designated Facility Owner or Operator.4rtificatlDn of receipt of hazardous materials covered by the manife!L!�cept as noted in IOT 18a A <br /> PrintedfTyped Name Sigg Month Day yea <br /> -P 'i C-1 al"1511 lam, <br /> (kf all n'r 8 1 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />