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Please print or type.(Form designed for use on elite(12-pitc))typewriter.) Form Approved.OMB No 2050-0039 <br /> UNIFORM HAZARDOUS 1-Generator ID Number 2 Page 1 of 3,Emergency Response Phone 4,Manifest Tracking Number <br /> WASTE MANIFEST JJK1 <br /> 5.Generators Name and Mailing Address Generatars Site Address lif different than mailing address) <br /> 16ILr W GFlA i LlIiL ku <br /> TPml CA Q.5 0A <br /> Generators Phone- 209 2-74M <br /> 6 Transporter 1 Company Nam; U.S.EPA ID Number <br /> `f"MENTAi SFPI►TCFs 77036 <br /> 7-Transporter 2 Company Name U.S.EPA ID Number <br /> WORLDWIDE RECOVERY SYSTEM INC. <br /> 8 Designated Facility Name and Site Address i EPA ID Number <br /> t35M US HIGHWAY 95 <br /> ,,„•,n M, <br /> AZROD4521146 <br /> Facilites Phone. ?"(11314 <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 Padding Group(tf any)) No. Type Quantity wt.(Vol. <br /> Q 1-4UN-RCRA HAZARDOUS WASTE 501-1(,(PA E :FiLTEni ) <br /> Z 2 <br /> w <br /> 3 � <br /> 14,Special Handling Instructions and Additional Information <br /> EMERGENCY CONTACT - CHEMTREC 1-800-424-SM WOES TERMINAL CERES W F'riLWILE R 961 1628 f;,j1frl <br /> PAPER FILTERS APPROPRIATE PPE EQUIPMENT an <br /> 15. GENERATOR'S10FFEROR'S CERTIFICATION: 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 /> marxed and labeledlplacarded,and are in all respects in proper cond'tion for transport according to applicable international and national govemmental regulations.If export 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. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(bl(if I am a small quantity generator)is true. <br /> Generatoes108efors Prinleeyped Name Signature Month Day Year <br /> J 16-Intemalacnal Shipments <br /> ❑Import to V.S. Export from U.S. Port atanirylexit <br /> Transporter signature(for exports only}•, hate leaving U.S.: <br /> DG 17,Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrintedlTyped Name Signature Month Day Year <br /> d 1 rf <br /> Transporter 2 PrintedlTyped Name Signature Month Day Year <br /> t- <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b,Aitemate Facility(or Generator) a S.EPA f0 Number <br /> J <br /> i.) <br /> Facility's Phone- <br /> W18c.Signature of Altemate Facility(or Generator) <br /> � - - Month Day Y62r <br /> a <br /> z <br /> W19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste Treatment,disposal,and recycling systems( <br /> d 1 2. 3- 4. <br /> 20-Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Ba <br /> Pdnted[Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENEFil <br />