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DT#P.O.Box 400 Sacramento,Ca.95812-0406hin 30 days.** co �,. **Generator,Mall a copy to: Form Approved.OMB No.2050-0039 Please print or type.(Form designod for use on elite(12-pitch)typewriter.} 2 Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number UNIFORM HAZARDOUS 1.Generator ID Number may' 1 800-424-9300008642965 WASTE MANIFEST f �L��l / Generator'sSlteAddress(if differentthanmailing address) 5,Genorator s Narne and Mailing Address , GeneraA....00o7 U.S.fPAIDNumber 6.Transporter 1 Company Name CAD982413262 EVEY reSn EnViCOflillental Services U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 84 Designated Facility Name and Site Address Evergreen 011, Inc. CAD980887418 6880 Smith Ave. Newark,Ca.94560 Facility's Phone: 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers Qu Total 12.Unit 13.Waste Codes 9a. No. Type Quantity Wt.1Vol. HM and Packing Group(if any)) z 2. U.1 C7 F CNVIRONMEN Al. 4. _.. 14. alHanc9pg Instruct ons and Additional Information ��y� �sl�, 2KCS—:5.— X30 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(plecardod,and are in all respects in proper condition for transport according to applicable International and national govemmental 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 EPAAcknowledgment 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)(if I am a small quantity generator)is true. Month Day Year Generator'slOfferoes;Printed/Typed Name Signature i16.Internalional Shipment ❑ ❑Eortirom U.S.Import to U.S. Po ntrylexit: �J Date leaving U.S 2 Transporter signature(for exports only): w 17.Transporter Acknowledgment of Receipt of Materials Month Day Year Transportr: rintedlType 31gIalure ,446 Traer 2 Printed[ryped Name Slgnatu Month Day Year r- 18.Discrepancy 18a.Discrepancy Indication Space4uantity El Type F]Residue ❑Part'al Rejection L_I Full Rejection ❑ Manifest Reference Number: U.S.EPA ID Number 181 Alternate Facility(or Generator) J_ C> u<- Facility's Phone: Month Day Year LOU 18c.Signature of Alternate Facility(or Generator) 0) 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems} 0 1, r�' 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Monitr Day Year Printed(fyped Nameignatu ATED FACILITY TO DESTINATION STATE(IF REQUIRED) CPA Form 8700.22(Rev.3-05) Previous dations aro obsolete.