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-- -3py to: r T80 P.O. Box 400 uacrarriart#o, CO. 95812-V4,06 Within 30 dayz. " Please print or type. (Form designed for use on elite (12 -Ditch) typewriter.) Gnrm Ann ,e.4 MAD KL. onan Anon EPA Form 8700-22 (Rev. 3-05) Previous editioris are obsolete.; �' - DESIGNATED FACILITY TO GENERATOR ED AL. T UNIFORM HAZARDOUS gnerator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST _ ?';XZ-0,-,V0j,!`� t f i 800-424-9-300 008642 5. Generators Name and Mailing Addre�s ^y r /„�� Generator's Site Address (if different than mailing address) �f ' J�' l CTi9�z f. G,¢' , 9 o NO V 0 4 2013 Generators Phone. 6. Transporter 1 Company Name U.S. EPA ID Number N M EN 91V ffir •rtrolirri"'ntal st vice3 k I- 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number - Everoreen{lit, Inc. 68840�ml b Ave. GAD98088T418 Nevvnf k, Ca. 94510 Facility's Phone: ga. HM 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, and Packing Group (if any)) 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type Quantity Wt./Vol. '104C /1 G>�P ADS— L%7S' eW t Allbt w. 4. 9 14. Special Handling Instructions and Additional Information , � ,�� -�� 0 � - 15. GENERATOR'S/OFFEROR'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, marked and labeled/placarded, 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. 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. Generatoes/Offeroes Printed/Typed Name Signature Month Day Year J F— 16. International Shipments ❑ import to U.S. ❑ Export from U.S. Port of entry/exit: z Transporter signature (for exports only): Date leaving U.S.: w 17. Transporter Acknowledgment of Receipt of Materials Transpo �tor 1 Printedrfyped Name Sign Month Day Year co Q Transporter 2 Printedrryped Name Signature Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space Quantity El Type 1:1 Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J_ U Facility's Phone: w 18c. Signature ofAltemate Facility (or Generator) Month Day Year Q Z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1. 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printedrryped Name Signature > Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editioris are obsolete.; �' - DESIGNATED FACILITY TO GENERATOR ED AL. T