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6 - <br /> -Ger erator,mail a copy tot Di.,,P.O.Sox 400,Sacramento,CA 08124"within 30 days- <br /> us <br /> Please print or e. Form designed for use on able 12-pitch)typewriter. FotmApproved.OMB No.2050-0039 <br /> UNIFORM HAZARDO1.Ge rentor(D Number 2.Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST Cis /l�Dd�v 9 Z 180"24-M 003024049 J J K <br /> e.Gener❑tot's Noma and Malifng Address -- �r,� �} Gonoralors Site Address(if different than mailing address) <br /> Generators Phone: <br /> 7 <br /> 6.Trans ortar 1 Company Name U.S.EPA ID Number <br /> Evergreen Environmental Services CAD982413M r <br /> 7.TraU.S,cerinoRM Environmental Services, Inc., Ea I umbo <br /> t 9322230 <br /> i 8.Designated FacIl ly Name and Site Address U.S.EPA ID Number <br /> Clean Harbom,SanJose. LLC i <br /> 1021 Serf"sea Rd:,Sah'Joier'^CA 95133 CAD059494310> <br /> radii Phone: <br /> t <br /> So. 9b,U.S.DCT DesariptIon(Including Proper Shipping Name,Hazard Gass,ID Number, 10.Contalnors 11,Total 12.Unit 19.Waste Codes <br /> HM and Packing Group(If any)) No, Type Quantity WINoI. <br /> j o X 1, UN1950,WASTE AEROSOLS,2.1,(Ltd. Oty.): 331 1)001 <br /> Z 2. i <br /> W <br /> t <br /> I. 4. <br /> 14.Special Handling Instru ons and Additional Information <br /> 961)Profile OCH430536, ERGO 126 cA;v�r <br /> Y470's," '. :. 7T3DQ 3 532 <br /> 15. OENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consyjnmerA are fully and a urately d scribed above by the proper shipping name,and are dasslfled,packaged, <br /> marked and Iabeledlplacarded,and are in at respoa8 in proper condtion for transport according to applicable 4n ma 1 and I govemmerial regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment uonfonn to the terms of the attached EPA Adtnowiedgm of Bent , <br /> I certify that the waste minimization statement Idenited In 40 CFR 262.27(a)(t I am a large quantity genoralor) (b ( am a a II quantity generator)la true. <br /> Goneralor' is P nted/fy d me Signature Month Day Year { <br /> t � <br /> a <br /> 16.International SNpments ;f <br /> Import to U.S. ❑Expor.from U.S. Port of ant .!exit• <br /> i Transporter signature(for exports only): Date leaving U.S.: <br /> 17.TransporterAcknowledgment of Racelpt of Material i <br /> j Trnnsporiar 1.dntedlTypad Name Signatu Month Day Year <br /> 'ransporto t y a Sfgnatur Month Day Yea <br /> 18.Discrepancy <br /> 18a•Discrepancy Indlcason Space <br /> ❑ Quanary ❑Type ❑Residue I_J Pauzat RoJedion ❑Full ReJedion <br /> Manifest Reforonco Nu bor. r <br /> 18b.AltaTats Padll y(or Generator) Manifest <br /> EPA ID Number I <br /> d <br /> U <br /> ►Br- Facility's Rhona: <br /> a 16c,Signature of Wmads Fadllly or Goneratoq Month Day Year <br /> X <br /> 19,Hazardous Waste Report Management Mellrod Codes(I.o„codes for hazardous waste treaunent,disposal,and recycling systems) <br /> LU ,. <br /> iL�1 L <br /> 1. <br /> 20.Designated Facility Owner or Operator CoNPoaflon of recelpt of hazardous materials oovowd by the manifest exospl as n in Item 18a <br /> Printed a or e Signature � Mon ay Year I <br /> EPA Form 8700-22(Rev,3-05) Prevous editions are obsolete. DESIGNATED FACILITY TO DEST ATION STATE(IF REQUIRED) <br /> M 1 <br />