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+ ssald—Pas�aq osla f ew U—' uui,... 1 Form Approved.OMB No.2050-0039 2 Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number �. JJ K mailing Address Generator's Site Address(if different than mailing address) CJS Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: 9a. 9b.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.Nol. O L 2. C3 ;E V 3. ET 19 2016 4. ENVIRONMENTAL HEALTH D PARTMENT 14.Special Handling Instructions and Additional Information , 15. GENERATOR'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 labeled/placarded,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. Gene rator'slOfferor'sPrnted/TypedName Signatures ��._ Month Day Year —1 1 16,International Shipments F- ❑Import to U.S. / Dupont from U.S. Port of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: 17,Transporter Acknowledgment of Receipt of Materials Transporter Printed/Typed Name y, -' r Signature r'-% Month Day Year Z Transporter 2 Printed/Typed Name Ar Signature i' Month Day Year M 18.Discrepancy � 18a.Discrepancy Indication Space ElQuantity ElType ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number a Q °r1i Facility's Phone: 18c.Signature of Alternate Facility(or Generator) Month Day Year Q O 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) - - LU 1. 2. T 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted)alterp.18a_ Printed7yped Name Signature r Month Day Year FPA Form 8700-22(Rev.3-051 Previous editions are obsolete. nFCIf;NaTFn FArI1 ITV TO GENERATOR