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Please print or type. (Forni'designed for use on elite (12 -pi ewriter,) Form Approved, OMB No. 2050 0039 <br />11HBORM HAZARDOUS 1 Generator ID Number 2. Page 1 of 3, Emergency Response Phpn 4. Manifest Tracking Number <br />7— <br />WASTE MANIFEST <br />006661-4,51 <br />5. Generator s Name and Mailing Address « Generators Site Address (if different than mailing address) . <br />nators hone:a o <br />6, Transporter i Company Name U.S, EPA ID Number <br />err Semi <br />7, TraCA <br />nsporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address <br />Eve mei 0111, Inc. U,S. EPA ID Number <br />1388- Smfth ado <br />Nmarkdmww <br />Facility's Phone: <br />ga, 9b, U.S, DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers <br />HM `and Packing Group (if any)) 11, Total 12, Unit 13. Waste Codes <br />No, Type Quantity Wt.Nol. <br />2. <br />UJI <br />I � 3. <br />it <br />14. ecial Hand ng Instructions and Additional Informaton <br />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 classed, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national regulations. <br />governmental If export shipment <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br />I certify that the waste minimization statement'dent�ed in 40 CFR 262:27(x) <br />and I am the Primary <br />(if I am a large quantity generator) of (b) (if I am a small quantity generator es true. <br />Generators/Offerors Printed/Typed N 'me <br />Signature <br />Month Day Year <br />.• <br />r Int national Shipm nts <br />import to U.S.. ❑ Exporf from U.S. Port of <br />entry/ext <br />Transporter signature (for exports' only): , Date leaving <br />W 17: Transporter Acknowledgment of Receipt of Materials . <br />�. Transporter 1 Printed/Typed Name Signature <br />O <br />Month 'x Day Year <br />Q Transporter 2 Printed/Typed Name Signature <br />1r <br />Month Day Year . <br />18. Discrepancy <br />18x. Discrepancy Indication Space <br />Quantity ❑ Type ❑ Residue Partial Rejection <br />Full Rejection <br />18b: Alternate Facility (or Generator) Manifest Reference Number. <br />J U.S. EPA ID Number <br />V <br />Facility's Phone: <br />W 18c. Signature ofAitemate Facility (or Generator) <br />j <br />Month' Day Year <br />Q <br />Z <br />9 LM Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LLJ 1'r+ <br />3: <br />4, <br />20. Designated facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previou9L editions are obsolete. <br />107 105; 1 <br />DESIGNATED FACILITY TO GENERATE <br />