Laserfiche WebLink
- *;* Q6n 3Tat01`, Mail acopy +,-%.-DTSC P.O. Sox 400 Saora,-, W n1o, Ga.. 95812-0400 within 30 days. * <br />D1a— nrinf nr tVnP lFnrm rlacinneri fnr i ica nn alite f12-nitrhl tVnAWrltpr.i <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. /_,G'�' DESIGNATED FACILITY TO GENERATOR <br />/E <br />NDE <br />RENT <br />UNIFORM HAZARDOUS V 1. G r for ID Number <br />WASTE MANIFEST /�pi�? (� �— <br />2. Page 1 of <br />ti <br />3. Emergency Response Phone <br />1-8�z 3 <br />4. Manifest Tracking Number <br />C %,J 7`=...J J 8ZM <br />5. Generator's Name and Mailing AddresC`r Generators Site Address (if different than mailing address) <br />CAM/ �I��v <br />7/ ' <br />"0/p/ CS-;p"X�i �S?os"` NOV 04 2 <br />Generator's Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />41 ENVIRONM <br />EVERGREEN ENVIRONMENTAL SERVICES C, <br />7. Transporter 2 Company Name U.S. EPA ID Number P <br />B. Designated Facility Name and Site Address Evergreen OII, Inc. U.S. EPA ID Number <br />8980 Smith Ave. <br />Newark, Ca. 94580 Cr' D960687418 <br />Facility's Phone: 510-795-4400 <br />ga. <br />HM <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />and Packing Group (If any)) <br />10. Containers <br />11. Total <br />Quantity <br />12. Unit <br />Wt.Nol. <br />13. Waste Codes <br />No. <br />Type <br />— <br />0.. <br />� <br />,y <br />LLI <br />7 r 'reit 3 j} <br />Aw <br />&5-o <br />I <br />2,` <br />4. <br />I J <br />�� <br />g <br />g/ <br />0.25-- <br />I iQC� <br />cSI 14 1 '4 <br />14. tial Ha I Wing Instructions yd Additional Information % — <br />945 ?4 AA14rd <br />'76-3 -17 11 -y 1`,9J? - �s" ���y-E <br />d- -7tih,9j- -1 <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 labelediplacarded, and are in all respects in proper condition for transport according to applicable international 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 th"Itachad EPAAcknowledgment 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 />GeneratoeslOfferoes Printed/Typed Name Si�natare n L`" Month � Year <br />i <br />k ( I �,, E4 <br />� <br />1— <br />116. International Shipments <br />❑ Import to U.S. Export fr S. Port of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials I <br />Transporter 1 Name ure % Month Day Year <br />, <br />a <br />jPintedfTyped <br />f <br />TransportPrintedFryped Name Signature Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejecfion <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J_ <br />V, <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Q <br />Z <br />h <br />19. Hazardous Waste Report <br />Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems)Uj <br />1. H/L/ I <br />2 8/ Li J <br />3. H) (, <br />4. <br />l <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 �. Signature � � � <br />Month Dafi-,' <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. /_,G'�' DESIGNATED FACILITY TO GENERATOR <br />/E <br />NDE <br />RENT <br />