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**Generator,Mail a copy to: DTSC P.O. Box 400 Sacramento,Ca.95812-04�within 30 days.** Please print or type.(Form designed for use on elite(12-p pewriter.) Form Approved.OMB No,2050-0039 UNIFORM HAZARDOUS I.Generat'or�IDT Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST ` z-,940 � 1 1-800424-9300 007038950 JJ K 5.Generators Name and Mailing SAddress / Generator's bile Address(it different than mailing address) " ' y_e� Generators Phone:Phone 6.Transporter 1 Company Name US.EPA ID Number EVERGREEN ENVIRONMENTAL SERVICES CAD982413262 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address Ever9 reen O11, 1 no. U.S.EPA ID Number 6880 Smith Ave. Newark,Ca.94560 CAD98DB87418 Facilirye Phone: 510-795-4400 ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(H any)) No. Type Quantity Wt.Nol. 13.Waste Codes L ✓� he ✓w - 3. I 4. i itial Handling Instructions and Additional Information - 76- - —ss- 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, 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 EPAAclmowledgment 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)(d I am a small quantitycalor)is true. GeneratcrslOferors PrintedRyped Name Signature Month Day Year Jas 13 J 16.International Shipments z 1:1 Import to U.S. ❑Export from U.S. Port of entrylexit: Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials O Transporter er 1 Printedliyped NamMonth Day Tear 1-1 140015 — 0 Transporter 2 Printedrfyped Na a Signature Q 9 Month Day Year K F } 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type y El Residue ❑Partial Rejecticn ❑Full Rejection Manifest Reference Number: (~ 18b.Altemate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: w iBc.SignaWre olAltemate Faulity(or Generetor) Month Day Year Q Z h19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 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 Ise Prntedrryped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)