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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2056-0039 <br /> UNIFORM HAZARDOUS 1. newt ID Number T.Page 1 of 3.Emergency Response Phone 4.Man ihst Tracking Number <br /> WASTE MANIFEST /ap3� 1 1-800-424-9300 003336019 JJ K <br /> 5.Generators Name and Mailing Address/, /i/ /.�.�� &�f Generators Site Address(if different than mailing address) <br /> (, G/�4/','�� ln�`e� /7`A . li✓1 SQ7 <br /> /Generahors Ph -��m�c� / "1C� /� <br /> 6.Tansportery CompfWen Cnvironmeenttal Services U.S.CAD982413262 <br /> 7.TransportCter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and site AddressEVergreen Oi 1, l nc. U.S.EPA ID Number <br /> 6880 Smith Ave. <br /> Newark,CA 94560 CAD980887418 <br /> Facility's Phone: 510-795-4400 <br /> 93 91b.U.S.DOT Desaipfion(including Proper Shipping Name.Hazard Class,ID Number, 10.CaMainers 11.Total 12.Ung <br /> HM and Paciang Group(t any)) FFT,,e Quantity WINd. 13.Waste Codes <br /> Iwo <br /> z T. <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information r/ <br /> NE/W-- — ` <br /> 15. GENERATOWSIOFFEROR'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, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable imemafionaland national governmental regulations If export shipment and I am the Primary <br /> Exporter,I certify that the contents ofthis ommignment conform to the terms of the attached EPAAcknoWedgmem of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(t I am a large quantity generator)of(b)(til am a shat quantity generator)is tue. <br /> Genefatoes/Offerors P is ype l Name signature Month Day Year <br /> 1 i6.International shipments El from U.S. Port of ernM/exit: <br /> F 13 Import to U.S. <br /> K Transporter signature(for exports only): Date leaving U.S.: <br /> IX 17.TansporterAdmaNetl t of Receipt of Materials <br /> OTransporter 1 Fnntedriy e / / Signature Month Day Year <br /> CL <br /> QTa 'nsporter2 PedrTyped Name Sign re Month Day Year <br /> K <br /> H <br /> 18.Discrepancy <br /> tea.Discrepancy Indication Space ❑ quantity 1:1 Type ❑Residue ❑Portal Re ection Full Ra ljedion <br /> Mantest Reference Number <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facilitys Phone: <br /> uu 18c.Signature of Alternate Faddy(or Generator) Month Day Year <br /> Q <br /> z <br /> 19.Hazardous Waste Report Management Method Cedes(i.e.,codes for hazardouswaste heahhKrt,disposal,and recycing systems) <br /> 1. 2. 3. 4. <br />