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• r, CG0T 64 . 0716 <br /> •*Generator, Mail a copy to:DTSC P.O.Box 400 Sacramento, Ca.95812-04W wI hln$0 days or <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.M04`M33 <br /> n et Tracking Number <br /> WASTE MANIFEST ��p3 0503Z t•. -1600-424-9" 0�4 9 0 8 6 3 3 JJ K <br /> 5.Generators Name and Mailing Address L n- <br /> �*v`S ,pLtim L s . Gene2lols S40 Address(if different than mating address) <br /> I(d�4�7 ZIFKI+AGt 4e[t701q IZB <br /> Generators Phone'. <br /> ` 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Vf Evergreen Environmental Services CAD982413262 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated reality Name and Site Address Evergreen 011,Inc. US.EPA ID Number <br /> 6880 Smith Ave. <br /> Newark,Ca.94560 CAD980887418 <br /> 510-795-4400 <br /> Fadi' s Phone: <br /> gar 9b.U.S.DOT Description(induhing Proper Shipping Name,Haaard Gass,10 Number, 70.Containers 11.Total 12.UM <br /> HM and Packing Group(if any)) No. Type Chattel Wil-vol. 13.Waste Codes <br /> 41VIV 11A,#CE 0aW4SIF, O!D <br /> 9 l/SED MSsor '� <br /> Z 2. <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Infamati <br /> 401- X411i(P"9IE'1 �CxSs �l <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described some by the proper shipping name,and are classified,packaged, <br /> marked and labelecifplacanded,and min all respects in proper mrdltiun for berspmt according to applicable Interna' at and rational governmental regulators.If expod shipment and I am the Primary <br /> Exporter l mi that tha mortems of this consignment conform to the tame of the ataeled EPAAcmowtMgnrent of sent <br /> I my that the waste minimization statement identified in 40 CFR 26211(a)(ff I am; large guantiy geneata)a -a4I uahtty gr s true <br /> Generators/OAerors Pdtded/Typed Name c - Signature jf Month Day Year <br /> �(, Z I 1 2t tel <br /> -a 16.Inlematimal Shipments <br /> ❑Import to U.S. L1 Export from U. Pot of entry exit <br /> Transports signature(for exports my): Date leasing U.S.: <br /> C 17.TrarspoterAckna.Medgment of Receipt of Materials <br /> C Transporter I,yPPr•,nled?ypad Name Signature �O�IAi) 'nth Day ora <br /> 6 l <br /> Q Transporter 2 Prin ype Name Signature, Month Day Year <br /> C <br /> r <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Spam ❑ Quantity ❑Residue ❑Partial Rejectionj <br /> Full Re action <br /> d 5 0 3A Manifest Reference Number <br /> 18b.Alternate Facility(a Generator) U.S.EPA ID Number, <br /> J <br /> U <br /> LL Facility's Phone', _ <br /> w 18c.SignaWm of Alternate Facility(or Generator) - Month Day Year <br /> 4 <br /> 2 <br /> H19.Hacamms Waste(Report Management Method Codes(1ce.,codas M hazardous waste tieaomnt,disposal,and recycling systems) <br /> 2. 3, 4. <br /> 20.Designated Facility Owneror Operator.CeNfoation of receipt of hazardous materials covered by the maddest except as ntled in Item 18a <br /> Pnntecil Name NgnaNre Month Day Year <br /> S � o <br /> EPA Form 8700-22(Rev,3-05) Proviou ibonsareobsolete. 10482.0823 OfOld-HATED <br />