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Please print or type.(Form designed forms8 on elite(12-.Vito)typewriter)' l ' Form Approved,OMB No,2050-0039 <br /> UNIPOR11 HAZARDOUS 1•Generator ID Number 7}: 2 Page 1 of 3.Etrieigency Response Phone 4-MaNtesf Tracking Number� 11 g� <br /> WASTE MANIFEST G i, a' y! '7 a� "� >lJ J <br /> 5.Generator's Name and Mailing Address Generalors Slle Address(f different than mailing address) s <br /> Balm 2 <br /> `X31 K tit-11HARD8{WMI, <br /> KAIPM ONWN NJ Ong? 1401.SCATO 011MR.ATE LAN.-M <br /> Generato?s Phone: <br /> 7sCA <br /> 6,Transporter <br /> 11CoCm;panyyName <br /> [�� y pT r Cs U.S.EPA <br /> fiIDNumber _ q <br /> 4k"30.�'`G':Ae kF'ti' , ��J€`�.li`i°'k+BB v ki;�+ 0 6'd 0 0 2 6� 7 7 p•� <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> a-Designated Facility Name andSlteAddress ;.,. - ... U.SiEPAIDNumber <br /> . <br /> AZ .53 <br /> Facifl y's Phone: s ) a <br /> ga. 9b.U.S•DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No, Type Quanllly wtivol, <br /> CX)1J0k-AKR FILTER-m-) <br /> 4. <br /> 14>Special Handling Instrucliuns andAdd'Eonal Information <br /> , MW <br /> fa�f.?a�s4ta $t ', sm � r �ra ` ,` , e OR c icMM-F <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATfGU; I lierebydeclare ihat'the contents of this'consignment are fully and accufalelydesedbed above by the proper shipping name,and are classified,packaged, <br /> marked and labeledfplacarded,and are in all respects in proper condition for transport according ID applicable international and national governmental regulations.if export shipment and I am the Primary <br /> Exporter,f certify that the contents of This consignment conform to the lents of the attached EPAAcknojv[edgment of Conceal. <br /> I cortify that thewaste minimization statement ldentitfed In 40 CFR 262.27(x)(if I am a large quantity gene€alor)or(b)(if barn a sm91 quantity generator)Is true, <br /> Generator slOffero�s Pr idled Typed Name Sig lu€e Month Days 9dYear <br /> � <br /> 16,International Shipments f� <br /> l l Import to U.S. ❑Export froth U.S. Port of enlrylexil i <br /> Transporter signature(for exports only); , Date leaving U.S.: <br /> W 1TTransporierAcknowledgmen IofReceipIofMaleda[s <br /> Tfansporterl PrinledffypedName a Slgnalure �? w <..:_. -..__._- Month . Day Year <br /> J FacIff <br /> d <br /> _Transpoffer•2PrintedlTypodName ' Stg0jIlo— Moolh Day Year <br /> 18.Discrepancy ✓ t. r•r {.... t <br /> 18a,Discypency tndfcallon Space 1 ❑Typ ❑Residue f ❑Partial ReJactimr ❑Full Rejection <br /> ❑ Quanti e <br /> J� E <br /> Manifest Reference Number: <br /> 18b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> J ' <br /> � ll <br /> LL Facility's Phone: <br /> W 18c,Signature ofAllernateFacility(or Generator) ' ' ' nn 9i Da y Year <br /> a r., <br /> . .. ........... <br /> 19.Hazardous Wasie'Repad Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU© 1 2. 3. <br /> 20.Designated Facillty Owner or Operator:Cerlifloa[lon of receipt of hazardous materials covered by the manifest excep€as nded In Item 18a- i <br /> Printed/Typed Name ` Signature I. Month Day Year,..1� - k <br /> FPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNMED P.AciLITY,Y0 GEWRATOR ' <br />