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*Generator,r#aratorr iVlail a copy to,DISC P.O.Box 400 Sacramento,Ca.95812-0400within 30 tlays*FormApprraYod OMB No.20500039 <br /> Please 'nt or ,(Form dost ned <br /> for <br /> use on elite 12-plteh)typewriter,) <br /> e <br /> UNIFORM HAZARDOUS 7.Generator ID Number 2.Page 1 of 3.Emergncy Response Phone 4.Manifest hacks Number <br /> WASTE MANIFEST C�►�Iop $ 3� 1 1 800-424-9300 004475200� JJ K <br /> 5.Generators Name and Maiiln0 Address Ws Sita Addmss p dlteran#than rnoiling address) <br /> V'46 <br /> Generator's Phone: U.S.EPA ID NY+r <br /> &,Trans, 1 x a s ,rT PC i Fdp <br /> .� <br /> – <br /> 7. U.S.EPA ID Number <br /> Transporter 2 Company Name <br /> 8,Designated Factkl Name and Site Ad r sss U.S.EPA ID Number <br /> vergreen I,Inc. <br /> 6880 Smith Ave. JUN 19 2015 CAD980887418 <br /> Newark,Ca 94560 <br /> FaciliC`s Phone: 510-795-4400 <br /> 989b,U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 1 11 11,Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) d ype Quantity Wt.Nol. <br /> �-- f' <br /> Z 2. <br /> 'Ww ,.... <br /> V 4 <br /> 3, <br /> ...�T <br /> i <br /> 14: cies HAndfing lnstnrctit and Aetd'ttinnal I rt ERG # 1 —,, 79" <br /> V 1 3 <br /> Use appropriate PPE <br /> 15. GENERATOW311FFERQR'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 international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the wasts minimization statement identified in 40 CFR 262.27(a)(If I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Gow!!�L <br /> 0mrs Pri pad N S tum Month ay Y <br /> 16.international IS <br /> ants Import to U.S. ❑Export from U.S. Port of entry/exit: — <br /> F- <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> tk 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter t P i ypad Namo Sl niti Day, Year <br /> CL <br /> �, . <br /> Z Transporta rrrrterlr fv arl Naoae Slgnajuro Month By Year <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Spacequantity t 1 Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> U.S.E�ID idtrnder <br /> 18b.Alternate Facility(or Generator) <br /> J <br /> v <br /> W FactiiWs Phone: Month Day Year <br /> W 18c.Signature of Alternate Facitity(or Generator) <br /> 4 <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 4 <br /> W 3. <br /> O <br /> 20.Designated Facility Owner or Operator:Certl8ca8on of receipt of hazardous materials covered by the manifest except as noted in Item 18a Mo=Dayy98rPr nt�d Ga—mor tEPA Form 5700-22(Rev,3 05) Prevvious editions are obsolle DESIGNATEDFACILITYT S T I �1( T 11(tREQUIRED) <br />