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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1'Generator 10 Number 2.Page 1 of 3.Emergency Response Phone 4.MaMfest Tracking Number <br /> WASTE MANIFEST I i0`006788 JJ K <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Generalar's Ph":t y <br /> 6.Transporter 1 C-T- Ka 11 lk - U.S.EPA ID Number <br /> -- t1'.'ir <br /> 7 Transporter 2 Company Name U.S,EPA ID Numher <br /> 8.Designated Facility Name and Site Addnoss U.S.EPA 10 Number <br /> .'a,:ifE', S+IF.IVH.t;Ef«iEfmrT ;?'4 t: , <br /> UNE R Q <br /> ik1Piz CiTi <br /> Fadiityls Phone: J;Kl-r:., <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total t2.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nd. <br /> 1. <br /> 1h;-3TE :,CILID'S (FILTER C4YE, <br /> a <br /> ~� <br /> rr <br /> LLI <br /> LU <br /> 2' '`I+�hlf+.(:P�. H,4 �*f?T7133 L1 ':3"r= :wstllfJ3 ii��r;IM :aI. LE gSt,iC,i I <br /> cS <br /> c�3DIM Wo <br /> 3. l <br /> I <br /> 4, <br /> 14,Special Handling Instructions and Additional Information p�v!D E'P&TO BE TRAINED 3rD-#�M 3011 F-RijY)A7L1'1 '4021 EFG'64 0 1, <br /> 94 90 _CAI 1)n it gt)ZI °M - I <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and aocumtely described above by dme proms shipping name,and are classified,packaged, <br /> marked and labeledlplocarded,and are in all respects in proper condition for transport according to applicable international and national governmental reguiations.If export shipment and I am the Pnmary <br /> Exporter.I certify that due contents of this consignment conform to the terns of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste mmirnization statement identfied in 40 CFR 262.27(a)(it I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> G atorsi0terors PrintedlTyped Signature 1 f(kmth Day Year <br /> - Name ure=, <br /> a 16,Inteina',"Shipments <br /> i— ❑Import to y to U.S. ❑Export from .S. Pon of entry/exit: <br /> Transporter signature(for exports only): Dale leaving U.S.: <br /> 17.Tran Acknowladgment of Receipt of MaterialsLU <br /> t ,� <br /> Tranap 1eNTyped Name Signa Mgnth Day Year <br /> q, ',i / <br /> 0. <br /> S ' +i.1�7- �/ ,fey C - I r TLi <br /> d Transporter 2 PnntedlTyped Name nature Month Day Year <br /> r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Humber <br /> 18b.Alternate Facility(or Generator) U-S.EPA ID Number <br /> U <br /> Faulkys Phone: <br /> w 18c.Signature of Allemate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> C7 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 4. <br /> Il la <br /> 20.Designated FacilityOwner orOperator:Certification of raccipt of hazardous matedats oovered,by the maimifest exceptasncledm kem488 <br /> Pltntearfyped: ane r5ighatare Month -P Year <br /> EPAForm'6700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />