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Please print or type.(Form designed for use on elite(12-p&ewdter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone -4.Manifest Tracking Number I .-:.I �.�-. I ins WASTE MANIFEST 1 014783182 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) Generator's Phone: 6.Transporter 1 Company NameVRU.S.EPA ID Number of 7.Transporter 2 Company Name 13%Bo C'E I U.S.EPA ID Number NOV 2 0 2015 8.Designated Facility Name and Site Address U.S.EPA ID Number % ENVIRONMENTAL HEALTH DEPARTMENT 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. 0 UJI Z 2. Uj 3. 4. 14.Special Handling Instructions and Additional Information 15. GENERATOWSIOFFEROR'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 intemational 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 ain a small quantity generator)is true. GeneratqrWOfferqrs Printed/Typed Name Signature Month Day Year z 1U4 J 16.Intematidn6l Shipments Import to U.S. ❑Export'from U.S. Pod of entry/exit: Transporter signature(for exports only): Date leaving U.S.: LW 17.Transporter Acknowledgment of Receipt of Materials I Month Day Year tE Transporter I Printedrryped NaKd"-- ;' CL U) Z Transporter 2 Printedfryped Name Signature Month Day Year fg I18.Discrepancy 18a.Discrepancy Indication Space Quantity El Type ❑Residue EIPartial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number Ca I L Facility',Phone: 18c.Signature of Alternate Facility(or Generator) Month Day Year Z V5L9 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 LU L 1 2. 3. 4. - 1 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 are obsolete. GENERATOR'S INITIAL COPY