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*C erator,Mall a copy to: DTSC P.O.Box 400 Sacramento,Ca.95312�0400 within 30 days.* <br /> Please Ont or e,(Form designed t>sru.w on elite(12-pllch)typewrrder.) Form Appruved.OMB ND.2050.0039 <br /> VNIFORM HAZARDOUS 1•Genarafor ID Humber Z Page 1 Of 3,lanarganoyReaponse A; 4.Man1fool Trask ng umbar <br /> WASIEMANIFEBT CA vao 6 1 1-110(3-4� 9300 007040164 JJK <br /> S.Ganeratnfs Nama and MalOng Address 7-1-14 Gr +,I IiZ Generator's Gb Address pf dilrerent Nan meU ng xddra��) <br /> 14ZQ P9 <br /> dal3ra�r3 Ptto� �� <br /> -Trenmportor 1 Company Name U.E.EPA IB Number <br /> EVERGREEN ENVIRONMENTAL SERVICES t CAD982413262 <br /> 7, ran:parter 2 Gcmpsny Name U.S.EFA ID Number <br /> 8.Dealgrtated Fadliy Nemo and 511eAddrese Errargreert Oil,l;t1C. <br /> U,S.EPA ID Mnbar <br /> 6880 Smith Ave... <br /> Newark,Ca.94550 CAD9=87418 <br /> Facg3Ma Phdire: 510.7954400. <br /> ga Pb,U.S.DDT DasctlpOnn(hdoding Proper Shlpplrg Noma,HvjW Clisk 10 NwiW 1d Crntd►rera 11.Tota) 12.Urdl 13,Wads Codes <br /> RM end Pacldrrg Cxoup(d a ry)) No. "Typo wouty M AFK <br /> 1. HQ_ZXI'd 0IJ-Jd{ X 11 <br /> r'ull. <br /> q MAZ077 �, - , <br /> C .} DM 7S f <br /> 3- <br /> 4. <br /> 14.Spedai Hoo ft instructions and AddBiorrel Informs on <br /> 15, GEN ERATOWSf0 ROKS CEI TIFICATION:I mby dedere that the eontark of lhls mnatgnmant are y gco=tely d. rt ad by the proper ahrpp'�ng norma,and am cbmstged,packaged, <br /> marked end labefadfpfacarded,and are In ap reapocts In proper cond ifon fm transport sccor&g to 90p abl tlonaland Won I g raguUnna.If export Qhlprnent end I am the Primary <br /> ExKder,I certify Nat the contanle of this corlalgemenl conform to the terms of the attached EPAA&nrnwlad a Ont. <br /> r I w l t the to minlmlrstron telsmenl Idenuriod In 40 CFH 26227(a)(91 ant a terga quantity genera! r a(b(fit am a I umnqy werelor)m bua- <br /> Genereta to medlryp Nerve Egnaw z Month Day <br /> Tat <br /> 18,Intama ham is Imwtto U, , Fxpat irom U.9. P of <br /> s <br /> Tronapormr.lgn7lure(for Ozportsonly): A' lea U&* <br /> 17.Trarwp%WA*nmMedgmenlorRecelptafMatdriala <br /> Twmpoder 1 P ntaruTyped Name Signature' month tIaL Y r <br /> Tran a 2 P ole em9 Signatura Iftnth pay Year <br /> te,Alscreparwy ' <br /> tea.0lOcrepancy tndtcaft Space ❑Perdei lief eMbrr Ful Rejection <br /> © Ooandty 0TV'eeardue <br /> .... <br /> Manifest stance Ntcnber: •, <br /> 18b.Memo Fed(tly(or Gerwratnr) ! US,EPA ItLalber . <br /> � Fad s Phw,a; <br /> iftzinnaturo ofAllafflateFeally(orGanoratnr} n ey YM <br /> 19.Hazardous Wasto Repots Maw gament Malhgd Codes 0 g.,cedes Aw hltaafdous wails traatmerrt,dl9Pasal,and regr3agsysts-)!.i <br /> 2• 3. '•' 4. 1; <br /> 23.Designated Fadlity Owner or Dpera=CerdBcallon of racaipt cit h mrdous aafadais davered by Ute madrBat except as paled M Nem 18a <br /> Prlatedlrypgd Name SItIn Month Day Year <br /> a 16211 it <br /> FPA Fnrdi 87blY-22(Rev.MS) 17revInuseditl6ntapachsoiele, (3NATED FACILITY TO DESTINATION-STATE(IF REQUIRRQ) <br />