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Please print ortype.(Form designed for use on efde(12-pitch)typewriter) Form Approved.OMB No.2050-0039 <br /> •� iin(FORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3.Emergency Response Phone q 4.Manifest Tracking Number <br /> WASTE MANIFEST 617-CA47.1 J J K <br /> Piemeralors Name and Mading Address Generators Site Address(if ddferent than mailing address) <br /> tf.��'rr_"",...:��da�+'e;<•,..T t'r'ay"ire,, <br /> Generators Phwe:� r t .$ ..a bme. V, <br /> 6.Transporter 1 Company Na JJ kZS__.ttBP TDFtJ .--%(c i .i <br /> •� cur .&ti .1 2C�$� .°. h�. ...�r���.�""u"`"?:)�'• <br /> 7.Transporter 2 Comparfy Name s U.S.EPAID Number <br /> S.Designated FamFty Name and Site Address - U.S.EPA ID Number <br /> E a MS'Fgtlhxb,' � 'itf <br /> rLD &1&4Pic ., 4A 61v,µ LA'. -' 1 / <br /> Facilty's Phone: " #r.,�.°` -'Lfbt ) r_...1�-\� <br /> ea. 8h.U.S.DOT Description(irxLud'mg Proper Shipping Name,Hazard Class,ID Number, 10.Cwfainers 11.Tow 12.Unit <br /> HM anndtPaddng Group Of any)) No. Type Quantity WtJVol. 13.Wada Codes <br /> C <br /> iJ �.r u�yr"!`a d,E:o#yl°1�+ N9,.a(-�'co��a �6��6 ,Faa�,c� �'e�� r °1•� - y <br /> 3. <br /> FILTER RECYCLING SERVICES' RIAL O FAC, ITI, PA <br /> ADPO04AAA21 UAC.Z THIE APPROPRILE PER T S OR <br /> a. <br /> AND WILL ACCEPT THIS WASTE S SHIP ED. � <br /> Special Handling Instructions and Additional tdwgatiwt. One or more of the material listed on this manifest may <br /> ,r.9va�5e.a+ °!t J.divdas6- e° s�ar',Q ®i ` be reoycladas altee�lative dally rn7vr.{AGC),or other Y <br /> method"wh�il1ch uses the /material In or on the land <br /> l .rSS' <br /> 15. GENERATOR'S)OFFEROR'S CERTISCATION: 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 /> tmaked and labeled/placarded,and are in ag respects in proper condition for transport according to applicable international and national govemmenw regulations.If export shipment and I am the Pdmary <br /> Exporter,I certfy that the contents of this consignment conform to fhe terms of the atadhed EPAAclunoaledgroent of Consent. <br /> I nastily that the waste minimization statement identified in 40 CFR 262.27(a)It I am a large quantity gwerai4)or(b)if I am a smaa quantity generator)is true. <br /> G toes/Offerors Protetl7Typed Name i Signals" Month Day Year <br /> 16.International Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Pod of entry/adh <br /> Z Tmnspoder signature(for exports only}. Date leaving US.: <br /> w 17.TransporterAcknmvfedgmentofReceipt or '. s �,. 1 <br /> �.Tmnsporter 1 PrintedfTyped Name Signatu —1VMwth Day Year <br /> Z Tmnsportesr2 Printed/]?RedName - ahud — Monti - Day Year <br /> CKH <br /> 418.Discrepancy - <br /> 18a.Discrepancy Indicaton Space ❑ oaeny ❑Type Rejecfiw <br /> Residue Partial FIB Rejecfion <br /> Manffest Reference Number. <br /> 18b.Allemate Fadity(or Ganaalor) U.S.EPA ID Number <br /> U <br /> LL Facility's Phone: <br />____�. Nbunale Fa,9lity{orGeneratar) -�--. - -Meath---Day—Year <br /> z <br /> CD +q.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste beatmw%disposal,and recycling systems) <br /> 2- L1 � 3 4. <br /> 20.Designated Facility Owner or 21rater.Certification of receipt / ous materials covered by the manifest a=%as noted in Ilam taa <br /> Pdnteaf Typed Name ('N ( Signore j"�h Month Day <br /> Year <br /> �3 <br /> EPA Forth 870022(Rev.3-05) Pre bus editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />