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tNq Please print or type,(Form designed for use on elite(12-pitch writer.) Form Approved,OMB No.20SM039 UNIFORM HAZARDOUS 1. nerator ID u r1 2.Page 1 of 3.Emergency Response Phone 4 Manifest Tracking Number WASTE MANIFESTD (.. 1 . . f ,. 0.018 2 7 28 0 JJ K 5,Generators Name and Mailing Address^�� /O Generator's S' Address{'d ��n mailing address 4?10 44-700Q Genetat 6.Transpoorrteprh1 Company Name U.S.EPA ID Number Evergreen Envirv_rnnenU Senn wse ,�- 'x 7.Transporter 2 Company Name U.S.EPA ID Number PSC,I ndUstri;W OUtsourmi l fw... B.Designated Facility Name and She Add U.S.EPA ID Number .1 st.I lxrlturyj,ENII:.. 'Na�Itrl�srDti ►a 'F 0 L .rl . Fool' s Phone: arFa':#`"Y: ' '..3;r•�,'x.,- }„ . ;�'' .'1 :.r, t.'. ,< ..r.:4•.a ''SF! r„1. moi' ,-r. :rr Ff:. ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing�G,ro1up(If any)) No. Type Quantity Wt.Nol. rx W X *A ' 1 z1 Z 2. W 3. 4, 14.$ el Handl g Instructions and Additio n mrievon 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 claselfled,packaged, marked and Iabeledlplacarded,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 Exporter,I testify that the contents of this consigninent conform to the terns of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement Identified in 44 CFR 262.27(x)(If I am a large quantity generator)or(b)(if I am a small quantity generator)Is true. GeneratorslMrors Printed/Typed Name Signature Month Day Year �czrISL 3 8� D� -1 16.IntemationalShipments ❑Import to U.S. ❑Export from U.S. Port of entrylexft: Transporter signature(for exports only): Date leaving U.S.; 17.TransporlarAcknowiedgmenl of Recelpt of Materials Transporter 1 PW&drrype Signature Month D Year 131 )07 Transver 2 Pdntedrrypad Name Sig re oath Day Year 18.Discrepancy 18a.Discrepancy Indicaton Space ❑ Quantity. ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manlfest Reference Number. 18b,Aftemate Facility(or Generator) U.S.EPA ID Number LL Facility's Phone: U 18c.Signature of Altemete Facility(or Generator) Month Day Year a z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recyciing 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 PrintedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)