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"Generafor.m pas' )TSC,P.O.Box 400,Sacramelto,CA 55815 )WWII 30 days'' <br /> Please print or type.(Form designed for use on elite(12-p@ch,;;pewwff.) ' Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Mani estTrackin Number <br /> WASTE MANIFEST CAM24874M 1 I-BOD-424-9300 003781215 9JJ K <br /> r,Generators Name and MalingAddress Gerwratofs Site Mosses(ddiferent than rustling address) <br /> C�jGA c�OIOAIN� COMPANY OGI TONACAB Zp5 REFRESHMENTS USA ING <br /> Generatofa Phone:• 845t8J E <br /> 6.7rerspoda 1 Company Name U.S.EPA 10 Number <br /> EVERGREEN,ENVIRONMENTAL-SERVICES CAD982413262- <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Qesiyiated Facility Name and She Acidness U.S.EPA ID Number <br /> EVERGREEN 01L,INC, <br /> 6180 SMITH AVE: CAD880987418 <br /> ARK• CA 84560 <br /> as s ane: <br /> ger go.U.S.-DOT D&2ifficrt Qncudig Proper Shipping Name,Hazard Class,ID Number, 10.ConLw1d 11.Total 12.U4t <br /> HM and Padding Group(ifary)J 13.Waste Codes <br /> No. Type Quantity WUVaL <br /> z NCN-RCRA HAZARDOUS WASTE,LIQUID �r^ sz3 <br /> (DILY WATERI 1 TT gicla C� <br /> z 2. <br /> w <br /> co <br /> 3. <br /> 4. <br /> 14.Special Handling Istmctionsad AdcNWial hdonnafion <br /> A BMB ERG 171-9bl Document# <br /> 1.18804 <br /> 15. GENERATOR'SIOFFFADR'SCERTIFICATON: Ihereby declare that the contents of this consignment are fully and accuraleF/described above by the propershippkg name,and are classified,packaged, <br /> maked and labeledlpacawded,and are in all respects In proper condition for harspod according to applicable international and national gmemmanlal regulations.If expert shipmentad I am the Phnary <br /> Exporil I mrtby that Ore canlanls of this consignment conform to the @ms of the attached EPA AcknoMedgment of Consent. <br /> Iar*gal the waste muimlrarwn slztemem iderxified in 40 CFR 26227(a)(111 am a large quantity generator)a(b)(BI am a am[quardtygenadarn he. <br /> Genemtceal0lfeans PmtedRyped Name Signalure - _ Month Day year <br /> S LJILLIJ �{„/LSC' /f <br /> 16.nhrralional Shipments <br /> T- ❑ImW to U.S. ❑Exparthan U.S. Pat of an(rylextt <br /> z Tansporterstgnatae(for exports ordy): Data leaving U.S.: <br /> w 17.TianspataAcknoeieddgmml ofReedpt of Materials <br /> Transporter l PdntediTyped Name Signature Mash Day Year <br /> 4to <br /> c r2 n/ yped / <br /> Trerspale 'Signature Martin Day Year <br /> K <br /> 18.Discrepancy <br /> 1Ba.Discrepancy Indication Space ❑ elms" ❑Type ❑Residue ❑Parted Read. ❑Full Reiac6m <br /> Mandest Reference Number. <br /> 18b.Allemale Facility(a Getarata) U.S.EPA ID Number <br /> J <br /> U <br /> ra FacTd>•s Phone: <br /> w M Signature ofAtemate Faclty(or Generator) Math Day year <br /> zz <br /> N18.Hazardous Waste Rmpod Management Method Codes(i.e.,codes for hazardous vmste treatment,disposal,and recycling systems) <br /> ._ --_ o f. 2.. 3. 4. <br /> en 4 <br /> 20,bahmdedFadIuy0wns aOpsagr CemSafian afmcelpt of hoard"materials crcrered by the modest except as noted in Item l8ar�- <br /> Pmtewlypsd Name St nature Month Day Year <br /> l r, : // 12 11 <br /> EPA Form 6700.22(Rev.305) previousaAilionsareobsolele. DES ATEDFACILITY TODESTINATION STATE(IF REOUIRED) <br />