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N Please print or type.(Form designed for use on elite(12-pitch),typewdtec) Form Approved.OMB No.2050-0039 1.Generator ID Number 2.P ge 1 of 3.Emergency Response Phone 4.Manifest Tracking Number 1 UNIFORMHAZARDOUS � 013435237 ,1JK WASTE MANIFEST t] u'ifi>'-ti8!3-L�tEt' lipGeneratofs Name and Mailingg,,A��ddtn Generator's She Address(if different than mailing address) [`'ACtFd'. uQ!Fl`llintt3.'m"T;::kfi1L;P.710N $T -iy 3AGr FCrfi 221 sircGl•:rnpa.rF: �z1s Generator's Phone: X1I"I`K'iD"'0 6.Transporter 1 Company Name U.S.EPA ID Number Genua W. t.nwrr.tnc. B 2 4 2015 ::;,F«:.cYht7019 7.Transporter 2 Company Name ENTAL U.S.EPA ID Number 8.Designated:FAgil,y Nryr iandi§ltgAddress c �a l�Fp10 U.S.EPA ID Number 01141"Of".Cr. C41? 3 Facility's Phone: '1 C. ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Tatal 12.Unit HM and Packing Group(ff any)) No Type quantity WtJVal. 13.Waste Codes 'F 1 IV tt/-'.; f.rfisTL FLAtvVV--B E LICLIV 'pwrIMP Kot&PI inl,,> a part;Of 0 D?Pf 4a z 2 w co 3. 4. 5 e I,Ij riling ln,Wctig s and Additional Information :T4Uartc� 7"'Q e. F iJic.•[?1-I.:tM 11aL'—U$Ma\ a� / 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 labeledlplamrded,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 ceNfy that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. —- ---— Icedify that the waste minimization statement identified in 40 CFR 262.27(a)if lam a large quantity generator)or(b)(if I am a small quantity generator)is true. - - - - GenemtotslOfferotsPdntedRypedName Signature - Mopill ay Year 16.International Shipments r— ❑Import to U.S. ❑Export from U.S. Port of enWexit Transporter signature(for exports only): Date leaving U.S.: w 17.TranspoderAcknoWedgment of Receipt of Materials ' :T Transports Prinlgdrrypedr�me l Signature�� s I! "v+' Month Day yepr. Transporter 2 Printed/Typed Name Signature t Month Day Year K 1-_ 18.Discrepancy 18a.Discrepancy Irdicallon Space ❑ quantity ❑Type ❑Residue ❑Pamal Rejection ❑Full Rejection Manifest Reference Number. 181h.Altemate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: r w 18F Signature ofAltemate Facility(or Generator) Month Day Year Q i Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 2. 3. 4. 20.Designated Facility Owner or Operator.Cedificefion of receipt of hazadaus materials covered by the manifest except as noted in Item 18a Printedltyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY;