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0 • OTSC. 01678. 14S2 <br /> Please print or type.(Form designed for use on elite(12-pitch)typev nter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,GeneratorID Number 'p 2.Page I of 1 Epnver Response Phone 4.Ma ifest Tracking Number <br /> WASTE MANIFEST c��3�p OZ7f 1 "'" ' 0 3468700 FLE <br /> 5.Generators Name and Mailing Address Generators Sde Address(if diff amid than mailing address) <br /> Conlyankirm Ret70ers LLC, Stora$ STi�SES <br /> 7180 K011 Ceft Parkway,Surge 100 /2G� 7, /qz1/-zr h Li m <br /> Pleacartlun,CA.94566 �c/Gl/s7 t"r d 9.52/d <br /> Generators Phone: 949.289.5286 <br /> 6.Transporter I Company Name U.S.EPA ID Number <br /> IBR ENVIRONMENTAL INC. I <br /> CAR000203109 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8,Designated Facility Name and Site Address US EPA ID Number <br /> FILTER RECYCLING S RVICE INC. <br /> IBD W.MDNTE SF.BLOCKNGTON CA.92316 CA0982444491 <br /> Faplitys Phone: (909)873-4141 <br /> ga 9b.US.DOT Desrsiplron(including Proper Shipping Name,Haeard Class.ID Number, 10.Containers 11.Total 12.Uhl 13.Waste Codes <br /> HM and Packing Group if any)) No. Type Ouantlty WINoi. <br /> -5- <br /> 0 011,09-r <br /> / /YoS•`C.ts l7vs� �fi/va3/ 0A"• sS <br /> /!an .ee144 it vis. <br /> 3. <br /> 4. <br /> 14 Special Handling Instructions and Additional Information <br /> 9i� y/srr, nc.3a0 r(� l <br /> 15. GENERATOWSIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are hilly and accurately desodbed above by the proper shipping name,and are classified,packaged, <br /> marked and labelediplacarded,and aro in all respects in proper condition for transport according to applicaNe international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I cenify that the contents of this consignment conform to the terms of the attached EPAAcknovvledgmenl of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(f I am a large guanbty generator)or(b)(if I am a small quantity generator)is true. <br /> ane a sr0 emrsPinSignature an ay Year <br /> x A3 x lca_,_A ,5--1 y <br /> �� <br /> J 16.Imilmabanal Shipments <br /> ❑Impar)boU.S. El Export horn U.S. Port of entrylem: <br /> Trans iter signature for extent;only): Dale leavmg U.S.'. <br /> w 17.TranspoderArkno,Nedgment of Receipt of Materials <br /> Transporter)Pnled/Typetl ameSignature Month ay ear <br /> Z Transporter Printed/Typed Nameignature Moral, uay Year <br /> LeLAS <br /> L Yl, <br /> 18.Discrepancy <br /> 1 %,) df%4V" <br /> 18a.DiscrepancylMira,ion Spam ❑ Opantiy Type ❑ ❑Partial Rejection ❑Full Rejemon <br /> j1�� Residue Co+�'glnf W41G j to I3V7 PrT�y�e /toy?;-3c <br /> Manifest Reference Number <br /> 18b,A31emale Family for Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Q <br /> n <br /> Facility's Phone: <br /> w 18c.SgnaMe of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> rA <br /> 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous wade treatment,disposal,and recycling systems)/ <br /> 0 ,. 1 y/ 2. 3. <br /> N/u/ 4. <br /> 20.Designated Facility Owner or Ope or Codification of receipt of hazardous materials covered by the manifest except as noted in Item lea <br /> PhnledrTyped Name f1 Signature �—Day Year <br /> EPA Fou 8700-22(Rev.3-05) Previ us editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 10921.1498 <br />