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Generator, Mail a copy to: DTSC P.O. Bax 400 Sacramento, Ca. 95812-M within 30 dayL* <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) Form <br />UNIFORM HAZARDOUS .t. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Man <br />ifest Tacking Nu <br />WASTE MANIFEST 1-6-;j{Y.. 24-230 <br />5. Generator's Name and Mailing 14Address ^j <br />Generator's Site Address (if different than mailing address) <br />.2 I-qj Ir - Eil�Iil,SL�1� psi <br />) &A q .5 <br />Gene tor's P one: <br />EVERGREEN MVIRONMENTAL SERVICES <br />7. Transporter 2 Company Name <br />8. Designated Facility Name and Site Address Evergreen 011, Inc. <br />6880 Smith Ave. <br />Newark, Ca. 94560 <br />Facility's Phone: 510-795-44M <br />ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />HM and Packing Group (if any)) <br />LLI <br />W YA *111ANA <br />f'*N i i W14An uS R.,K6VI -!k>114 <br />U.S. EPA ID Number <br />I <br />GAMM1 <br />U.S. EPA. EPA ID Number <br />U.S. EPA ID Number <br />CADM874 J. <br />10, Containers <br />11. Total <br />Quantity <br />12. Unit <br />Wt.Nol. <br />No. <br />Type <br />3 <br />D11 <br />ADD <br />P <br />a <br />7 <br />ablm <br />gas <br />P <br />Z 1 Dol 11000 1 P [—.- <br />OMB <br />No. 2050-0039 <br />8_JJK I A <br />NOV 0 4 201 <br />' TAS <br />1LTH DEPARTM NT <br />13. Waste Codes <br />14. Special Handling Instructions and Additional Information <br />-i'`i�oTl K =fi ? !�' --- ------ b f ► -r z$ ryJ :.; 1rc_ <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations. if export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generator's/Offerors PdntedrFyped Name Signature Month Day 1 <br />16. international shipments— <br />Import to U.S. <br />r s <br />Export from U.S. Port of entrylexit: <br />Z Transporter signature (for exports only): <br />Date leaving U.S.: <br />w 17. Transporter Acknowledgment of Receipt of Materials <br />6i Transporter 1 Printed/Typed Name <br />Signature <br />Month <br />Day Year <br />Mi <br />U) <br />Transporter 2 Printed/Typed Name <br />Signature <br />Month <br />Day Year <br />t- <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity <br />❑ Type ❑ Residue ❑ Partial Rejection <br />❑ <br />Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />J_ <br />V <br />LL Facility's Phone: <br />W 18c. Signature ofAltemate Facility (or Generator) <br />Month <br />Day Year <br />a <br />z <br />619. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />W 1 HIt 2. 3Hi I. 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 c Signature /"' Month Day Year <br />J C11c,.— ./c OLI I I l 1 <br />EPA Form 8700-22 (Rev. 3-05) Previous editio s are obsolete. DESIGNATED FACILITY TO GENERATOR <br />