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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number- -- UNIFORM HAZARDOUS r� - 1 r WASTE MANIFEST �' �- � �. 7 , RECPAhOn 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address C;(2) �5�_ JUL 31 2015 3L5Generator's Ph'fi-w. f Z-R'! 6.Transporter 1 Company Name U.S.EPA ID NiEWRCNMENTAL HEALTH FLUIDS, 1W PERMIT/SERVICES 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number T WO IN. 17TH. LONG 2CH,CA vim:CI Facility's Phone: ga 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity wt./Vol. i 0 �Q 1.c� 1`cie� V1 a.�. i 3'AK 3 T E a3 ',f4 ti«, -I- _ Y Z 2. V TI R?REF M- lCM WASTE WAS f(Iftg3r (1F• ,r!F aF�f=9rr OR Ffi1JSE Cp.. ;,y&OVaf ,,'.INC Or, -FS iNF F g-rry U't: I 3' i7XI`4rTS CiPAbnTZ TO'rj,'FK By t : U&IIEUT OF 70XICSL' iAPICECJN. -- 4 TOG _�.d t _-__. 11 RE50TI 12 i7dViR0 9E�'.tF_r4GtT"i -t*Cry IN CCOPZA CE tVrTH Ti LS OVISV, I ----- !UE RFSOURCL+C6#tSFr.V+-77L��: anti ,VT1?'i A_ OF 1476"OCI'Fflr""ii ALL Of' T1{ - � � 4. LOTTO S ACCEPT i-tiE REF CE .LL WASIF ANb L INE V'AYM HAS BIEN HANL U.A, ! "CCORDENGF.Y K--T-.- - f 14.Special Handling Instructions and Additional Information 15. GEN ERATOR'SIOFFEROR'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, marked and labelediplacarded,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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator's/Offeror's PrintedlTyped Name Signature Month Day Year J 16.International Shipments j El Import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: UJ 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name- Signature Month Day Year Month Day Year z Transporter 2 Printed/Typed Name { Signature', 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U W Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z S2 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1, / 2. 3. 4 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as/inoted in Item 18a Printed/Typed Name: / Signaturef Month Day Year / A�7-4.1 /21 L- �•' �. - ✓L%in ti(�` EPA Form 8700-222(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR