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; <br /> Please print or type.{Form designed for use on elite'?2• iiah <br /> t P )tyPewritar,} <br /> UNIFORM HA2ARDOUS t Generator IO Number ���Ge, <br /> me Form Approved.011 No.2050-0039 <br /> rgen 3 Re}u nse Ph me 4.hi F T <br /> WASTE MANIFEST , f t r u �� <br /> 5,Generator s r"Nome rd M uy Address, F k eR <br /> L <br /> � d;, le afs S A essi{ �rfter 41hs 1,8 a4dre s} <br /> Z 1,j <br /> i <br /> Caenara€ars phi � Al _ <br /> S i ft ap , f <br /> 6.Transporter 1 Gom;rany Nat ' <br /> C X4rl FOV,FIVPr,'ta;W,kibs,I f ,,r., U:3:EPA€DNumber <br /> 7'Imrisperter2Comp Name <br /> U.S.EPA ID Number <br /> 8.Dasignaled Facility Na rne aM Sita Address <br /> ° MAL <br /> U:S.EPA ID Number <br /> I r ,CA917%PSA <br /> Fadlitys Phicns: <br /> NHM <br /> :-av:d�packlnlij <br /> S.DOT Description(including Proper Shipping Nance,Hazard Class,ID Nun�nr, <br /> Group(if any)) 10•Canto nnrs 11.Total 12.Unit <br /> I <br /> No, Type Quantity iNtJ�/ol. 13-Rate Codes <br /> � # <br /> uj <br /> METALUj <br /> OIL FILTERSa <br /> 7`) <br /> 1 Spera i FLon� irtebue#rons r Jtai rmahan d,r z * T ,, <br /> 15. GENERATOR'StOFFEROR'S CERTOCATION: i hereby declare that the contents of this consignment are fully and accurataiy described above by the proper s#afppfng name,end are classTred,packaged, <br /> marked and I8beledjpaa6rded,and are in all resmis in proper condition for transport accardirhg to appltcable international and national govsmmanta! r <br /> Exporter,I t ft'batt the contents of this Consignment conform to the terms of Phe attached EPA Ackru:mied p�en1 of Co tseaL rare ifations it axpad sh pmsni and i am the primary <br /> 1,1ea t rt'chat„ 4ivaste n}rhi zdts2 t ldlerrurn#idanut ed in;C CFR 262.27taj(d!em a large nuantity generator)or( (if am <br /> lf( a smalr quantity gcs (eTor)is tr e. <br /> Cie akz sd Pe ` d Name - <br /> S,nature tyfanth <br /> � ) Ray Year <br /> ta... ., ,.J#��r C Y5 'L.µ'd „'�fiFsj� I f <br /> U� 7 <br /> io nal Shipments f ti <br /> Import to U.5. �Expert from U.S Port ai enlrY�e t1 <br /> rier signature}tar axparts only}; <br /> Date leaving U.S.: <br /> ift spaderA.dvomedgrnen€otReceptofMate afi <br /> ter t P i,lewrflyped Narne;7 $ r <br /> }' Sgna re <br /> Month [}ay Year <br /> ier 2 Pnrnednyped NameSignaturenth Day Year <br /> epancy .repancy Indication Space f—1 <br /> I.......I Q;tanttyTYPa (�`� <br /> t_J Residua PadiN Rejection t_J li Rejbdion <br /> 18b.Alternate Facility(or Generator) Manifest Refaren a Number: <br /> -� U.S.EPA ID Numbi�r <br /> Facil4y's phone; <br /> w 18c.Signature of Altemsta Facility lot Generator) <br /> Month Okay Year <br /> 4e.Hazardous Waste Report Management M._ i Codes Ii.e.,codes for hazardous waste treatment,&orlsal,and recycling syMiams) <br /> LU <br /> 1 2 4 <br /> Ll <br /> 20.Daslgrratad FacBity O�rner ar L}partor:Ce nictation at rexlp€of hazardous materiais covered by the manifest except as noted in Mean 18a <br /> °rintedtTyond Name <br /> £ SN <br /> ature fknl� t$Day �lgaar <br /> d ' � b P j a� 5.."v ✓ ufi 6S 2 T <br /> FPA Fnrm 8700-22(Rev..3-05) Previous editions are obsolete. <br /> DESIGNATED FACILITY TO GENERATOR <br />