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L -0 O) N <br /> Cl) please pnnl or type(Forms desi netl O N N <br /> O UNIFORM'HAZARDOU g I.Gene 3Se,o Noiel�.2pilch)typewriter I <br /> S Pone Approved.OM9 Na.2950-P099 O <br /> Z WASTE MANIFEST 2.Page 1 of 3.Emergency Resaonse Phone 4.Manilest Tracking Number I.- N <br /> S Generators Noma ina k5,r,iin4Address 017468 534 JJK <br /> D , Ceneralers Sue Address N diderent than ma-ling address) C O <br /> 2. <br /> CD <br /> D o CD <br /> Genemlor's Phoa: 2rr:..- . <br /> Z fi-Transpnne'I:n:,r,w Name 3 <br /> 3 O. <br /> tTl '-N VIJ US-FPAI0 Number <br /> T ansPodc D <br /> _ TrAL SEF-11;t;:r O C <br /> .. tans Name .,r._: - <br /> SYSTENII INC us-PPA Io Namher <br /> N CD <br /> a-Designated Fr:tt,,I,, antl SNe Add CA P ' S1 <br /> ess <br /> U.S.FPA 10 Number O <br /> `F C <br /> N <br /> Faurily',pMne: - i,Z F.5315 <br /> 13449828 A 7 <br /> ga. LLS,DOT❑escnption(ineknding <br /> NM andProper Hazard <br /> Shipping Name, Class,10 umber,Nr++ <br /> anPacking Group(it any)) 10-Containers it.Thai 12.Unit (D <br /> 17-Waste Cordes <br /> � <br /> "01-1-RCRA H No. Type Quantity wuvcl. 3 HAZARDOUS WASTE.SULtt�(t?ELY SOL4D,PAPER FILTERS'; <br /> t52 � <br /> w G(vi 20 P 1 - <br /> W 2. rD <br /> Ln <br /> e--F <br /> O <br /> 3 N <br /> V <br /> I CT) <br /> 00 <br /> LrI <br /> W <br /> P, <br /> 14-Sperlat Handling Instructions and Additional Infomtadon e v <br /> O <br /> EtJERGENCY CONTACT.-CHEMTREC 1-800-424-933C 1'vOES TE R9[fY61 'PROfiILE#931:1EZ623NF2$IfvlP0I2 OILY SOLID. is <br /> PAPER FILTERS: m APPROPRIATE PPE EQUIPMENT (D <br /> $�20 2 SJ <br /> m <br /> 15- Gr;NERATOR'SIOFFEROR'S CERTIFICATION:I therebydeclare that the contents of this coni nmant are full and accurately described above h the proper Packaged. <br /> O- <br /> g y y y p per shipping name,asci are dassifiad,p g <br /> marked and labeledlplaearded,and are in all respects in proper condition for transport according to applicable international and national govemmental regulations.Itexport shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent r-r <br /> I certify that the waste minimization statement identfied in 40 CFR 262.27(a)(Ni am a large quantity generator)cr(b)(if I am a small quantity generator)is true. S <br /> Genera slrxferods Prinledff ameC _ S'rat re Manlh Day Year O <br /> C <br /> o ( �* <br /> J 1fi.Inlernadonal Shipments <br /> r ❑ CD <br /> Import .S. ❑FxpodfremU.S. Padotenlrylexit: Q <br /> Transponer signature(for exports only)'. Date leaving U.S.: fD <br /> v1 <br /> W 1T.Transporter AchrrowledgmentofRemo ofMatenal- Cm <br /> Tran P nledffype ame Signature Month Cay YBar 7 <br /> Ito rDQkd <br /> z Transporter PrinledfTyped Nai Signature Month Day Year Q <br /> 4 C7 <br /> r^ <br /> O <br /> 18.OistYepancy `G <br /> 11fa.D scdepancy Indication Space Quantity ❑Type Ll Residue ❑Partial Rejection ❑Fukl Rejection <br /> Manifest Reference Number. <br /> F US EPAID Number <br /> tab.Nlemate Facility(or Generator) - <br /> J <br /> 47 <br /> Facility's Phone: Month Day Year <br /> W lec.Signature of Altemale Facffity(or Generator) <br /> rII <br /> 4 <br /> z <br /> 1g Hazardous Waste Report Managernant Method Codes It a,.codes for hazardous waste treatment,disposal,and recycling systems) <br /> 4. <br /> CD <br /> O 0 <br /> 20.pasrgnamd Facdsty UwtW or opef�CertfGcalwn o1 receipt of haza does matelots covered by the manifest excopt as nded In Item 18a Month Day Year (Q O <br /> Q <br /> PdnledlTyped Hama 3 _ <br /> EPA,Form 87W-22(Rev 3-051 Previous editions are absDlele. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> �J <br /> O <br /> v w <br /> � rn <br /> (D N <br /> O (3J <br /> O <br /> W <br /> O <br />