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Please print or type.(Form designed for use an elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page l of 3.Emergency Response Phone 4.Mfa}n9(a}st Tracking Number FS <br /> WASTE MANIFEST V v r VES <br /> 5.Generators Name and Mailing Address Generators Site Atltlress(if tliRereat then mailing address) <br /> Generators Phone'. <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U,6.EPA 10 Number <br /> JUL 0 7 2015 11, <br /> .Designated Facility Name and Site Address ENVIRONMENTALU.S.EPA ID Number <br /> Facility's Phone: <br /> rUnrOACYT4Agra 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number. 10.Containers ,1.Total 12.Unit 13.Waste Coda <br /> HM and Packing Group(if any) No. Type Quantity Wit./Vol. <br /> o � <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping rams,and are classified,packaged, <br /> marked and latmedlplacarded,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 certay that the contents of this consignment conform to the terms of the attached EPAAcknawledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(ti I am a large quantity generator)or(b)(RI am aAmpMunimityge true. <br /> Generatofst0fil'i PrintegRyped Name SignaW Month Day Year <br /> 1J i 'v <br /> F 6.International ShipmentsLj <br /> Import to U.S. ❑Export from U.S. Portofeniry/axil <br /> Transporter signature(for exports only): Dale leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> H' Transporter PentedfTyped Name Signature - M 1 Day Year <br /> Z Transporter 2 PnnledlTyped Name Signature - Mo� Day You <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Ouantity ❑Type ❑Residue ElPaNal ReJecfim ❑Full Rejection <br /> Manifest Reference Number. <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> W Ise.Signature of Alternate Facility(or Generated Month Day Year <br /> Q <br /> Z <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous wase treatment,disposal,and recycling systems) <br /> C 1, 2, 3 4. <br /> 20.Oesignated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifeat except as noted in Item 189 <br /> 11 nted yped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />