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06/15/2013 14:20 20952c" -''E B01"E'T VJAIREHOUSP pg PAGE 10/13 <br /> 3 8 'n r '40, <br /> t1c.P.0,!3_91 DOS, ana7., <br /> Please print or type.(Form desicdned for use dn elite(12-pitch)typewriter.)typewriter.) Form Approved.OMB No.2050-0039 <br /> ;I.4Ge ,rotor O.Nurnbgr I of Ememganq Rsspnst Phone Number <br /> UNIFORM HAZARDOUS <br /> WASTE MANIFEST IWA -O-= 2554 JJK <br /> 24 <br /> n Generator s Name and Meihg Address 4—r <br /> Generotor's Phone: <br /> 6,Transporter 1 Company Name Un rn%Z, <br /> Ev��;-C?,-80q anvk-oil-mental sevtr-ez U.S.EPA ID <br /> - NIN 21 2 013 <br /> 7 Transporter 2 Company Name <br /> 3.Designated Facility Name.and,ReAddrcss, U3.EPAIDNiATkw,- <br /> Evergmer,Oil.Im. ENX%=tJTAL <br /> &A-0,01 Smith Ave. H ENT <br /> 1-4,awav-,Ca.945W, <br /> FgdliVs Phone: <br /> ton�ndudinq Proper Shipping Reins,Har 10.Containers il.Toml 12.1.1nit 13.Waste Codes <br /> g, 9b.U.S.DOT DeSCrip zard GlaSS,ID Number <br /> HM and Packing Gro6p(ffsny)) Nd, Type Quantity WtNol. <br /> 1l1 i2 <br /> LWL1 <br /> 4. <br /> -J-+14.S adal Handling Instructions and Addrdonal Informallon <br /> A? <br /> 15. GENERATofr$[OFFMOR!SCERT.[FICATION'.14W—by declare that t%cortenis of this are fully and accurately described above by the proper shipping name,aware dassifiad,packagqd, <br /> marked and Isbeled1placarded,and are III all respeoLs in proper condition for bansporr according to applicable irtematlonl and national oovemmental regulations,If Wrt shipment and I am the Primary <br /> ExpvAer,I certify that the contents of this consignment conform to the terms of the alias ied.EPAAcKnoWisaginent of Cansti,)L <br /> thatthka, aqTniafi0 <br /> min Statement )(if 1 gni ahirgi-quantity g am a sms!I quantity generator)IS TO, <br /> #BtIdentified in 40 CFR 262.27(a enanior)or(b)(if I, <br /> e&Typed twe MoHill a Day Year <br /> GEM"teSlOfferbes,PTI Name <br /> Import td <br /> U.S. <br /> :Tninsporls:rsivi atute(for exporLs onl): Date leaving U,S.: <br /> Ce 11.TmnspQrtarAcknowlediimont of Receipt of Materials <br /> Month Day Year <br /> Transporter 1 PrInteoiTyped Name <br /> Ser <br /> Mont) Day Year <br /> 2-Transporter 2 Printed/Typed Name <br /> 10,01scrapancy �ull Rejection <br /> 18a.Discrepancy Indlai Coll SPaCe Type R's)5jefU12 ❑Partial Rejection <br /> Manifest Relbrance Number. <br /> lob.Aitenate Facility(or Geneptor) U.S.EPA ID Number <br /> Faclilly',Phone: <br /> ca Month Day year <br /> A 19.Hazardous Waste Report Management Method Godes(La,codes for hmjdous waste treatment,disposal,and recycling BYFIC7.--� <br /> 2. <br /> Iq / 135 <br /> M Designated 1`3dlityOwner oroporator CeTtlfiCstion of teceiat of hazartlous materals cov5red by the manifest KOE-Pi as F,,XLi;Fl Ik'q 132 <br /> PrintediTyped Name Month Day ear <br /> 61gnaulre <br /> EPA Form 8700-22(Pay.3-05) Previous editions are obsoietr. DESIGNATED FACILITY TO GENERATOR <br />