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o.veneiaiu,a rvanm aria man ng nocress Generators Site Address(if different than mailing address) <br /> JUCONSTRUCTION MATERIALS <br /> • <br /> S:TRACY 9L'J0. <br /> TRACY,CA 55377 <br /> Generators Phone: - <br /> 6.Transporter I Company Name - _ U.S.EPAID Number <br /> EVERGREEN ENVIRONMENTAL SERVICES CAD982413252 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Des nated Facilityry Name and Site Address - - U.S.EPA IO Number <br /> lERGREEN DIL,INC. - <br /> 5-31K)SMITI AVE, CA0980887418 <br /> NEWARK,CA 94%0 <br /> Facifty's Phone: 510-795-4400 <br /> ge, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Conlainam. 11.Total 12.Unit 13.Waste Codes <br /> HM end Paddlg Group(if any)) <br /> No: - Type Quandry WINoI, <br /> 401Zj 1 ) Dm <br /> z 2. <br /> W <br /> 3. <br /> a. ,. <br /> 14.Special Handfing lnsku "onsandAdditionallmomtation - - -•' <br /> ploflle�3lj erg 1-71 drum size ? <br /> 15. GENERATOR'SIOFFEROR'S,CERTIFICATION:Ihereby declare that the contents of this consignment are fully and accurately described above by the proper shippingname,and are classified,packaged, <br /> marked and IabeleNplacarded,and we in all respects In proper condition for transport according to appricable international and national governmental regulatbns,if export shipment and I am the Primary <br /> Exporter,I certly that the contents of this consignment ronfam to the terms of the attached EPAAcknowiedgment of Consent <br /> I cerfiy that the waste minimaabon statement identified in 40 CFR 262.27(x)IN I am a large quantity generator)a(b)(ifI am a small quanfity gen rator)Is true. ' <br /> .Genegslotherors Printedflyped Name Sigda, Month Day Year <br /> Ll ' f LLL- <br /> ri 15.1 temationai Shipments - <br /> z - ❑Import to U.S ❑Exporl fern U.S. . Pon of entrykaRi <br /> Transporter sbirmhae(for exports only): Date leaving U.S.. <br /> w 17 TranspaterAdmimledgmeM f M <br /> of Receipt of <br /> Transported Pdme{V Name Signature Month Day Year <br /> uaZi -;I- <br /> 4 Transporter _ rilited/lypetl.Name I - Signe re - Month Day Year <br /> o: <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Ouen6y ❑Type ❑Residua <br /> ❑Padiai Refection ❑Fu0 Rejection <br /> Manifest Reference Number: <br /> �- 18b.Alternate Facility(a Generator) - U.S.EPA ID Number <br /> J <br /> U <br /> Fecillty's Phone: <br /> C 18c.Signature of Alternate Facility(or Generator) _ Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(I.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> 20.Designated Facility,Owner or Operator.CerdfiMS n of receipt of hazardous materials covered by the manifest except as noted in Item 1 a <br /> Printedfryped Name Signature Month Day Year <br /> .PA Form 8700-22(Rev.3-05)Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />