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Please print or type, (Form des UNIFORM HAZARDOUS WASTE MANIFEST for use on elite 5. Generatdr s Name and Mailing Addre`/�%�' �"�u �4 V2 C �s'i� ��jC rle—i erfa- or Phone: 6.TranspoV&aaaaNnvironrl l) Services 1 17. Transporter 8. Designated Facility Name and Site Addres reen 011, Inc. 6880 Smith Ave. Newark, CA 94560 Facilitys Phone: 510-795-4400 ya, 9b. U.S. DOT Description (including Proper Shlpping Name, Hazard Class, ID Number, HM and Packing Group (if any)) c IX Z 2. LLJY 3. Emergency Response Phone Site Address (if different than Form lanifest Tracking Nu 00333 CAD982413262 U.S. EPA ID Number U.S. EPA ID Number CAD980887418 OMB No. 2050-0039 4 JJK 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type Quantity Wt.Nol. 575 C� zr 5- 1 4 14. Special Handr g Instructions and Additional Information �. 9� iii �z 3 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/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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment 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. Generator s Printedlfyped Name Sig Month Day Year Y 16. International Shipments � ❑ Import to U.S. ❑Export from U.S. Port afentry/exit: z Transporter signature (for exports only): Date leaving U.S.: 17. Transporter Acknowled t of Receipt of Materials Transporter 1 PrintedlT Neme / Signature Month Day Year O �O CL QTransporter 2 ➢ ntedffyped Name Signatu H 18. Discrepancy 1Be. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue Manifest Reference Num 18b. Alternate Facility (or Generator) V LL Facility's Phone: W 18c. Signature of Alternate Facility (or Generator) Q z N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1 2. 3. 20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature ❑ Partial Rejection U.S. EPA ID Number 4. Day Year ❑ Full Rejection EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)