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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 of 3.Emergency Response Phone d.Manifest Tracking Number `,Cc WASTE MANIFEST - YES 5.Generators Name and Mailing Address Generator's Site Address(if dAferenl than mailing address) r_Ct '�A•_ L�' 4.W QUANTA ti(_N Generators Phone: 6,Transporter 1 Company Name U.S.EPA ID Number GE IV ED RE 7.Transporter 2 Company Name U.S.FPA ID Number r 7 2015 S.Designated Facility Name and Site Address U.S.EPA ID Number ENVIRONMENTAL. Facili 's Phone: - HFA)TN 11COA OTAACAIT 9a 9b,U.S.DOT Description including Proper Shipping Name.Hazard Class,10 Number. 10.Containers 11.Total 12.Unit 43.Waste Codes HM and Packing Group(if any)) No. Type Quaofity WIN01, 1. K W 2 3. 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 IabeledlplawNed,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 t0 the terms of the attached EPAAcknowtedgment of Consent. I canny that the waste minimization statement identified in 44 CFR 261(g I am a large quantity generator)a(N tgl am a small quantity generator)is true. Generator'stO6erm's PrintedlTyped Name Signature Month Day Year —t16.International Shipments ri F El Import to U.S. ❑Emam from U.S. Pat of entrylexiC z Transporter signature(for exports only): Date leaving U.S.: Of 17.Transporter Acknowledgment of Receipt of Materials _ K Transporter 1 Ptipled(Typed Name Signature _ - Month Day Year 115. Z Transporter 2 PrinteifTyped Name Signa.R `� Month Day Year 18.Discrepancy i 18a.Discrepancy Indication Space ElQuantity E Type ❑Residue ❑Partial Rejech. ❑Fug RaJallon Manifest Raterence Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: W 18c.Signature ofAgemate Fadlity(or Generator) Month Day Year Q Z H19.Hazardous Waste Report Management Method Codes(io codes for hazardous waste treatment,disposal,and recycling systems) 0 1-, 3.2. 4. 20.Designated Facility Owner or Operator:CeNfication of receipt of hazardous materials covered by the manifest except as noted in Itam 1ga 1 PrinkdRyped Name Sgnature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR