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�IFo nsse on elite (12 -pitch) typpeen., <br />• Form Approves OMB No. 2050-0035 <br />WORMASTE RANI <br />(' "- _ >:., ;� Number <br />ops .-_ <br />i <br />2. Pae 1 of <br />g <br />3. Emergency Responsa Phone 4. Manliest Trackin Number- - <br />9 <br />003774594 9JJK <br />i WASTE MANIF <br />ST '-�-000303419 <br />1 <br />4- <br />800-024-93X7 <br />Na,T� <br />ttiliLtTb FY <br />Honing^^' Generators Site Address(N differentthan mailing address`. <br />1 ' <br />4219 MORAD <br />k LN. <br />STOCKTON, <br />9521: . <br />C-ersatos Pnone: <br />91 6-257 -539 <br />6. Transporter 1 Wm <br />any Name J.S. EPA IC Number <br />EVERGREEN <br />ENMRONMENTAL SERVICES CAD9824132fQ <br />7. T2nsporter Z Cc <br />rry Nate U.S. EPA!D Number <br />i <br />Sit=_ Address U.S. EPA ID Number <br />SOW SMTH <br />AVE. CA0980887419 <br />NEWARK, CA <br />94580 <br />5111.795-44DO <br />Fatiirtys PSone: <br />ge <br />9b. U.S. D <br />Description ncludmp Proper Shipping Name, Hazard Gass, ID Number, <br />10. Containers <br />it. Total 12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />ono Packin <br />Group (u ary`j <br />Quantity WCNoI. <br />DM <br />4z a <br />} <br />2 <br />I <br />I <br />i ) <br />3. <br />h 1 i <br />i <br />4. <br />i <br />1 <br />14. Spt Handfi <br />it <br />Instructions and Addition -al information <br />profile <br />erg13� . <br />15. GENERATO <br />SIOFFEROR'S CERTIFICATION: I hereby decare that the contents of this consignment are fully and accurately descnbed above by the proper shipping name, and are classified, packaged, <br />marked and I <br />led/placarded, and are in all respects in proper condition for transport according to applicable intemabonland national governmental regulations. If expod shipment and I am the Primary <br />Exporter, i oe <br />tifty that the contents of, this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br />I certify that I <br />a waste minimiuroa statement identified in 40 CFR 262.27(a) (d I am a large quantity generator) or (b) 91 am a small quantity genealor) is true. <br />oeneralr�QRe o <br />Printed(Typed Name ., Signatdre t ' Month Day Year <br />• <br />�j 16. International S <br />`- <br />consents <br />moort to U.S. ❑Export from U.S. Port of entrylexic <br />= Transporter sign <br />ire (for exports onry;.. Date leaving U.S.: <br />17. Tmnsportar <br />W <br />a gment of Racivin of Materials <br />Transporters FM1n <br />AT .e SignaNre Mon <br />y <br />�Year <br />G Transporter 2 Pn <br />yped Name Sgn e - Month Day Year <br />r <br />18. Discrepancy <br />!Be. Discrepancy <br />ndicabon Space _ Quantity ❑Tyrre Residue PaNaRejecton Full Rejection <br />ection <br />Manliest Reverence Number. <br />18i. Alternate Pa <br />1ity(or Generator) U.S. EPA ID Number <br />J <br />U <br />LL <br />I <br />Facluys Phone: <br />w 18c. Signature 01 <br />Timate Facl@p (ar Genaram,) <br />Month Day Year <br />2 <br />( <br />19. Hazardous V <br />safe Report Mznagemem Method Codes (i.e., codes for hazardous waste treatment, disposal. and mcyding systems) <br />W <br />2. <br />3. 4. _... __.. <br />za. Des gnated <br />ao!iry Owner cr �peralor: Cerftauon of receipt of hazardous maledals covered by rhe manifest except as nded in Item 188 <br />II+ P rtedRyped N <br />me Signature Month Day Year <br />EPA Form 8700-2 (Rev.3-05) Previous editions are obsolete. -- {firiAi.ZE 'S ,C-;L.1T"T0- 0ES7?`, AT104 STAT E ( 1 F R_ 0--j <br />