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"Generator, mail a copgy to 0TSC, P.O. Bax 400, Sacramento, CA 95812.nann rxrl+hr .onr w ; <br />' <br />Planes OMt ofNoe. (Pnmr daalonad far non �„ em, rah- <br />�carvrvwi cu rAGLLI l Y Tu oESTINATION STATE (IF REQUIRED; <br />NIFORM HAZARDOUS t'G a�lorl, ON°mbar E. PagetW 3.Em ' • oTumber vert. OMB No. 2050.0039 <br />0�3._.., _....., _4. <br />(i ergpncy Response phone 0.Manireet Tmehing umber <br />WASTE MANIFEST 1., <br />5 <br />;1-800-424-9300 003308907 JJ K <br />Generators Name and MI Add <br />l - Genemlo Ib dress fdlRermllhen mal ad e <br />zqAl <br />6 ��q�%� <br />�J • 1 (l' �7 �Yl�lf%�'?ASi `.✓ / <br />earatWs Phil .S�' <br />6. <br />Tmnapoder 1 Company Name <br />Evergreen Environmental Services U.S.EPAIDNumbar <br />7. <br />TinarepDrarZComfoary,Name CAD982413262 <br />US. EPAIDNumbsr <br />S.Designated <br />FecNry Name and$be Addmss Evergreen 011,Inc. U.9.FPAIDNumbar <br />6880 Smith Ave. <br />Newark, CA 94560 <br />Ms Phone: CAD980887418 <br />S. <br />9b. U.S. DDasa, l Ilan (Ilm7hx.B r�re P/m/qo m, H^,firazaN Class, Number, <br />-S!Kh3lp3 p <br />Unk <br />No. <br />Type <br />QuarfityIZ <br />WA <br />t IXI98 <br />0 <br />WCmlalnw,endPadAMGmupQry <br />? rCFl <br />�OT <br />'m <br />u2 3 <br />zIn3gN-a,ID <br />�i <br />DWate%ale� <br />I <br />3S <br />s <br />4. <br />74. <br />p� <br />pedalH dI �mdin s� Adtlltlonal infarmagon �qyM ,(res rqP+%�61-�„ �/'�j/J / (J <br />/g—� <br />f�3z-j/3YS e7 -j LPA <9•�—(ZO <br />,J"`^ <br />T& <br />DE1(ERATORUSrOFFEROR'SCERTIFICATION: Iherebytleakrs llmltha contents aflhla condgnmenl are fully and eecuralely desamed eboveb the <br />y �0per pMg name, erdam alesdfled, pedoged, <br />marked and lebakd'phomded, and ere In ag mspecls In propercandllkn for transport armrding loappllcable lydemallonaland <br />national <br />ERorM, l cerUfy that bre contents of III conagnmentconharm to me loans Of the eheched EPAAdmawledgment of Consent govammen�regddions if export shbment and the pdrtmry <br />mdlfy matthawaste mlNmlaadon slatemenlldenNlNd In40 CFR 2b227(e) krge <br />Ge <br />QFI em a quantly genamlor) ar (b) (IFI am a smell quanlll. genaralm) Is We. <br />Bator's Pdn ed/iypetl Nom@ Sg yre . <br />Monty Day Year <br />' <br />� <br />1& <br />lamatlonel Sh manta 230.oa <br />❑Impart to US. ❑Exportimm U.S. •" , <br />S <br />Tr <br />Potatentrylexfl: <br />rshmoure(for exports only): Dela lea II U,S.; <br />17, <br />mnepodsrAdmowiedgmentofRecelplofmamdale <br />Cd <br />oderi Prmdlfyp me Signature <br />Manch D�aayy^ Y <br />y <br />H <br />' <br />poder2 Pdnl pedN ma N <br />Slg ure MSN Day Year <br />Impancy <br />I <br />1Be, <br />Iecrepenayhruch; ton9pece <br />❑ manly ❑Type ❑Realdue ❑PeNd ReJedlon ❑FW ReJedbn <br />Ta—b. <br />temete Faculty for Genamlor) Menlfesl Reference Numbed <br />U.S. <br />EPAID Number <br />v <br />UI <br />Fad <br />OW <br />leo, <br />Phone:^ <br />signature efAltemate r Generator) <br />Facplty (o <br />Month Day Year <br />W. <br />19: <br />1 <br />azardaus Wavle Report Nanagemanl Method Codes Q.e., codes for hazardous wade kealment disposal, and racyding systems) <br />//Yf y 1414/ 3. 4' <br />20. L <br />Pdnl <br />0819=00 rxRty O,marorOperatar. Cenflusnan ofrecelplat hazaI mledala covered by the manifest except as iwled is Item Vis <br />d ypetl NamSignelure <br />s. <br />54e�----voeth Day Yeer <br />EPA <br />Fo <br />8700-22 (Rev. 3.O5) pravio editions are absolete. <br />�carvrvwi cu rAGLLI l Y Tu oESTINATION STATE (IF REQUIRED; <br />