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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest_Tracking Number WASTE MANIFEST .I � �a - 5.Generators Name and Mailing Address Generators SiteLJIVe t F.tvgww NOV 2 3 2015 Generators Phone: 6.Transporter 1 Company Name •- U.S.EPA ID Number _ ENVIRONMEN_AL HEALTH 7.Transporter 2 Company Name A41T Number B.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt./Vol. _ p 1 I I I I f v L I I c7 3. I I I t I 4. 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. GeneratorslOfferors Printed/Typed Name Signature Month Day Year -j 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials j Transporter 1 Printed/Typed Name Signature Month Day Year N Z Transporter 2 Printed/Typed Name Signature Month Day Year f- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantit Type y yp Residue Partial Refection Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J C.) Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) C 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed(fyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENIER/ATOR'S INITIAL COPY