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lease print Or .e. Fprri�.desigt5ed for use on.ellta(12•plttb)lypewriter.) 'FormA proved,OMB No.2050.0.039- <br /> UNIF,#RM AZAt2C10U5. Gerieral4ri0 Number . . 2 Page 1 of 3.Emergency Response Phone 14,Manifest Tracking Number <br /> .. � <br /> 1NASTE:NfANIFEw$T #; I !0 <br /> JJK ij } •; <br /> 5,GenQratar s,Name and Mailing Address. Generator's Site Address(If different than mailing address) <br /> PEP RAY %", <br /> RAS N-1 ON J +8037 1.401 SO #T OF) ROK E LAW <br /> GonaratarsPnane: 209 % 54 <br /> 6.TranspoderICompany Name U.S.EPA ID Number <br /> WORLD II,M IRIO EWAL SERViGr t~ t €1 1 <br /> 7.Transporter 2 Company Name U.S,E A€D Number <br /> 01C DE rWWOV RY SYTL-MINS. . 00175422 <br /> m`e';fg7ab ,F!ffa b;6 "itd sleAitdi#ss <br /> Y0 04 YES I-L f <br /> 2730 E 13TH SY <br /> Al <br /> Facllilys Phone: (Q2 6 •M28 'I <br /> -ga, 9b.U.S.DOT Oascrlplfon(Including Proper Shlpping Name,Hazard Class,ID Number. 10.Containers 1t.Total 12,Unit 13.Waste Codes <br /> HM and Packing Group(If any)) No. Typo Quantity Wt1vol. <br /> N-RCCA VIOMMUS VNASTE,St'UD(PAPER FILT R+} X62 <br /> O <br /> 2. r <br /> 4. <br /> 14.Special Handling instructions and Additional Information <br /> CI-URREG 140W-424-9300 WOUS T RMINAU FROM L #961. 1616824MWS WEP.844 VIVIE <br /> FILTERS APP MIMATE PPE EQUIPMENT <br /> 15. GENERATOWSIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by iiia piti�ei shipping name,3iid are cla3sified,paika�ad, <br /> marked and labeledlplacarded,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 really that the contents of this consignment conform to the terms of the attached EPAAcknoMedgment of Consent. <br /> uanti enerafor or ff l am a small uanli enerator Is true. <br /> a iflamela a tY9 1 <br /> statement Identified 1n 4i1 CFft,28227 j (. I 9 <br /> I eerli Ihat the wash Minimization {1( r9 4 h!g , <br /> N <br /> enar toe's! fareys Printed.y eQName \ ;` 5 re=�" _ _ Month <br /> Day Year <br /> —i 16,hilemallonal Shipments <br /> Import to U.S. ��tt l—t Export WiwU.S.~^ Port of enlrylexit: <br /> Transpo4orsignature(for exports only): Date leaving U.S.: <br /> 17..Trahsporter Acknowledgment of Receipt at Materials <br /> F Transpojfer l dnlod{ypbd Nam J Signature i Month Day' Year <br /> t4 " . <br /> Tra s�}orter 2 Pdnfe ped N a Sig <br /> Ip Month Day 'Year <br /> F � tiC,+.f-C (,( `fid r r"`�� 1��% ��..'� �' <br /> i8.Dfscrepency '� <br /> ''l <br /> 1f—I 8a.Discrepancy Indication Space Quantity Type Rasidue ❑Parilal Rejecllon El Full Rejection <br /> iv <br /> Manifest Reference Numbar. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U i,3 <br /> tar. Fociliys Phone: Month Day Year <br /> 18u,Signature ofAltemale Facility(Or Generator) <br /> 19.Hazardous4iJasteltepo. a a ant a o as , . S o 18 as Y,�aTrdte'cydingsystemsj Y � <br /> L 1 2, 3. 4 <br /> 20.DesignatWaclllly Owner or Opemloi:Certificallon of receipt of hazardous malodals covered by the manifest except as ncd UTA I om 18a <br /> M Ili Day <br /> Printe ad Na b Signature , Year <br /> EPA Form 8700.22( ev,3.05) Previous editions are obsolete. I 1 EIS FACILITY TO GENERATOR <br />