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J • 0 <br /> Please print or type.A$' <br /> designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator IGD Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST � [O� 1--)3 2. <br /> 1 1-800-424-9300 J JK <br /> S.Generators Name and MailingAddress Generators Site Atldress(d different than mailing address) <br /> �Zo ( �ls1LtCT <br /> Ga er s h �r�. <br /> fi.7rensporarl CpPjp�mBn CnVlfOnmenfEl SerVIC6S U.S.EPA ID Number <br /> CVBr kf e - CAD982413262 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and SbAddmssEVergreen 011, Inc. U.S.EPA ID Number <br /> 6880 Smith Ave. <br /> Newark,CA 94560 CAD980887418 <br /> Fadlitys Phone: 610-795-4400 <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Clens,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(If <br /> my)y) Na. Type Quantity W1.No1, 13.Waste Codes <br /> w 2. <br /> 3. <br /> 4. <br /> 14.Sp Hand'Sinsiructiral Information cJJ9 �7� <br /> ��CC <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 labeledrplacarded,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 cmi that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> -I tardy,that the waste minimization statement identified In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(d I am a small quantity,generator)is We, <br /> Generator's/Offerors PnntatlRyped Name ^ � Sigra MonthDay Year <br /> —+ 16.International Shipments <br /> K 8 !a <br /> _ ❑Import to U.S. ❑Export from U.S. Pan of entrylexih <br /> Transporter Signature(for exports only): Date leaving U.S.: <br /> 17.TransponerAcknowledgment of Recegt of Materials <br /> OTransporter 1 P' /Typed Na Sgnature M Day Year <br /> A <br /> l 4r"110 <br /> Q <br /> Tmup5rter 2 Pdntedrryped Name Signature Month Day Year <br /> C <br /> f <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑T e <br /> Yp El Residue ❑Partial Rejection El Full Rejection <br /> 18b.Alfemate Facility(or Generator) Manifest Reference Number: <br /> J <br /> U.S.EPA ID Number <br /> U <br /> LL FaclIVs Phone: <br /> w 18c.Signame ofABemme Facility(or Generator) Monty Day Year <br /> 6 <br /> z <br /> W79.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste hestmant disposal,and recycling systems) <br /> 1' 2 3. <br /> 4, <br /> 1 20 Desgnated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pnntedrlypad Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />