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Please print or type.(Form designed for use on elite(12-pitcnr'ypewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS I 1 Ge er for ID u ber 2.Page 1 of 3.F7me�rg ency Response Phone 4.Manifest Trackin Number WASTE MANIFEST t) ) 0 1. '389 3 I fi<)t:))_ 7'!tt 7 ; ' C F L E 5. je,rt�►+f+w+Fj`iTl l iFRS'Lir1e�1� Generators Site Address('rf different than mailing address) ID441d iA215 St Generator's Phone: 6.Tra s orier Co any N�ne U.S PIDbe +,: �►►t1fa►` ►+ k ttt, Of�ltdttt a Set Ces InnsRE(;ElVhU 1059322250 7.Transporter 2 Company Name U.S.EPA ID Number AY 0 7 2014 8.4e$i natec�F_acili Name qnd Sits Addre$s U.S.EPA ID Number 1021.6v+'rYesra Road ENVIRONMENTAL 9311 luau,{:A`3u'M' HEALTH DEPARTMENT Facility's Phone: (4091 44 - i2 ga. 9b.U.S.DOT Description(including Proper hipping Name,Hazard Class,ID Number, 10.Containers11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes 1. .UN ,s_ . WALIf PAF OI :,JUM" i NOT IEX+: V0 GA 11. 3 !. 34 ' 1 I) kO I. D005 D001r,10007 w 3. 4. 14.Special Handling Instructions and Additional Infor nation 15. GENERATOR'SIOFFEROR'S CERTIFICATIO : 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 re pests 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 consic nment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement ic entified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is We. Generator's/Offerors Printed/Typed Name Signature Month Day Year .-.r 16.International Shipments z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature for exports only): Date leaving U.S.: rY 17.Transporter Acknowledgment of Receipt of Materia s W E� Transporter 1 Printed/Typed NAme at a Month Day Year N ,_ L tel - 1 , l zQ Transporter2 Printed/Typed Name Signature Morith Day Year t- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quan' ❑Type El Residue El Partial Rejection El Full Rejection Manifest Reference Number: 181b.Alternate Facility(or Generator) U.S.EPA ID Number J U Q vl Facility's Phone: B 18c.Signature of Alternate Facility(or Generator) Month Day Year a ry z Fn19.Hazardous Waste Report Management Method des(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. i?i i 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/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions a obsolete. GENERATOR'S INITIAL COPY %,,e art Ftar'13ct►s haS tF►e mppr#Urt P vwrwml,4 foo and w'14 Etc W Ott w*stt f1lk fflefir.fAlor 15 S$IffH}i(.