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State of California—Environmental Protection Agency <br /> Form Approved OMI No.2050-0039(Expires 9-30.99) See Instructions on back of nage 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(I2-pits writer. Sacramento,California <br /> UNIFORM HAZARDOUS Generator's US EPA ID No. Manifest Document 2. Page 1 Information in the shaded areas <br /> is not required by Federal law. <br /> WASTE MANIFE iAL io rio izi ' q �j �1 of 1 s <br /> Gen erQ�or's Nam p andd Mpi g Add r ss A. State Manifest Document Numbers' <br /> Cd'rd1.`� !'/4 7 Z 9 <br /> #J1 i,�t k ti.76dk1/1fN1 Ai <br /> y 2B. State Generator's ID <br /> 2't J <br /> LO A. Generator's Phone ( o ) ri 7 <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[ e ry .] <br /> Ln <br /> oa EVERGREEN ESI ONMENTAL SERVICES, D. Transporter's Phone <br /> O <br /> O r'd & <br /> t <br /> C? 7. Transporter 2 Company Name 8. US EPA ID Number £ state Transporter's ID[ e a d.] <br /> F. Transp4rretts Ghon <br /> a <br /> U 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID ` <br /> <i EVEFiGRMI till,INN, <br /> O b680 Smith Avenin H. Facility's Phone 0p <br /> u_ I�Ls'h!ruk,CA 94560 � 7 1 �}�� 7��-�44t7� <br /> J 12. Containers 13. Total 14. Unit <br /> a 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> U No. I Tye Quantity WI/Vol I. Waste NumbeT <br /> Z a. State <br /> ?� G li:A'RCRA TiAZARDOUS Y��i'rf,c:T E,1.1001) f �� �� 7 EPA/Or Kno her <br /> oE b State <br /> OD <br /> � R EPA/Other <br /> v A a <br /> o T stare <br /> 80 O 15PA/01her <br /> R <br /> LU d. <br /> State <br /> Z <br /> w EPA/Other <br /> v <br /> W <br /> N J. Additional Descriptions For Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> Z <br /> O a. b. <br /> a <br /> V) <br /> LU <br /> a d <br /> J <br /> a <br /> 0 15. Special Handling Instructions and Additional Information) <br /> P: <br /> 24 hour Emargerwy Response Telephone No., 01-11-1`1 R.Er, 807-424-9390 Invoice# ) // <br /> Z ? 'a ERG 171 10 : A PROTECTIVE tGUi6i;_,-_+dI' Sales l3rder# <br /> LU <br /> T_ <br /> 16. GENERATOR'S CERTIFICATION; I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed, <br /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> If I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> `n and the environment;OR, if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> °C available to me and that I can afford. <br /> p �-� <br /> >_ Printed/ pedN me `� ( Sign t yMonth Day Year <br /> u.l TR 17. Trans orter 1 Acknowled ement of Receipt of Materials <br /> w p Pri,,44H/Typed Mame e, ) Sigiiy i, ,...--- Mon toy .l Year-..; <br /> w S <br /> P <br /> a- 0 1 8. Transporter 2 Acknowled ement of Receipt of Materials <br /> TPrinted/Typed Name Signature Month Day Year <br /> LU E <br /> Vi p <br /> V19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (1/99) Blue: GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br /> EPA 8700-22 To: P.O. Box 400, Sacramento, CA 95812-0400 <br />