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102- L Please print or type.(Form designed for use on elite(12-pitch)typewriter.) 1EAor)oved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page'lof 3.Emergency Response Phone 4.Manifest Tracking Number ij " r, WASTE MANIFEST Svc &941,ml `�il 490 5.Generator's Name and Mailing AddressaM(tddrV4MejntV mVng ac" ,n J -'4n u j-; F4.g i -j n a I Tran a�it OCT 2 4 2016 Generators Phone: 6.Transporter 1 CompanX Name U.S.EPA ID Number „1L F=4i�jij3nNMFNTAL HEALTH 7.Transporter 2 Company NameDEPARTMEIll'EPA ID Number 8.Designated Facility Name and Site Address CUMN HAKKIRS DEER 'T WA h- L-L.C., U.S.EPA ID Number 1104351-115 F HIGHWAY 36 OUR TRAIL aoml- Facility's Phone: 9a. 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.Nol. NON RIG"NA WASTE 0 1,0IL 19,31AM-3F. AND i-OTTIER), N-A' ROD X 2. 3. -ho 97rc tv/201/6 01J 4. 14.Special Handling Instructions and Additional Information TSJ) 24 HR ENTEERGENLY #1-800-468-1760 (SK / "IFU rt I i 7'1.-i 21:1.1�'i Yr-11 F kv,F F i-.1 1, R V '7i 7 ll�6 Ti-1 R I T KI I 'I 1' 6:I%f T �'j f:j T E:rt CC, t� C 1'�D _ I 15, GENERATOR'S/OFFEROR'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. Generators/Offerors Pdntedrryped Name Signature Month Day Year 20 116.International Shipments Expo I- E]Import to U.S. rt from U.S. Port of entry/exit:it: M Transporter signature(for exports only): Date leaving U.S.: LW17.Transporter Acknowledgment of Receipt of Materials Li Transporter 1 Printedrryped Name Signature Month Day Year 0 1w lib X[Trensporter 2 P tedrryped Name Signature Month Day Year I18.Discrepancy 18a.Discrepancy Indication Space El Quantity El Type D Residue El P.rti.I Rejection El Full Rejector, Manifest Reference Number: I.. 18b.Aftemate Facility(or Generator) U.S.EPA 10 Number :3 LL Facility's Phone: C3 Uj 18c.Signature of AJtemate Facility(or Generator) Month Day Year !R z-0 1121) 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 LU 1. 2. 3. 4. 1 1 1 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a P tedfTyped Name Signature rin Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY