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"Oenttorator"I a Copy to:OT90,PA,Sw 4K t',apatr OND,CA$ 1l1"ftvAb 30 days� <br /> Please prh or Form ds ned for use on elitet2-plt^,h awrlter. Form Approved.OMB No.205MC39 <br /> lW_ <br /> UNIFORM ARDOU3 1.Oantvntorl���e�� 2,131100 1 of 3.Errrergi cyRe®Penxomo P 4' 009436996 <br /> �t5 4��-�9 5 JJ K <br /> WASTE MANIFEST i <br /> 8, �i�Nome and Gng Address Gsnenttds Site Addrase(V dFmfeht than mailing address <br /> � W1AY <br /> Qenemtot's Phone: 1�'� <br /> B.Tran 85Mtw 1 Company Nem" S EPA fD NUrtrher <br /> EVERIBREEN ENVIRONMENTAL SERVIM CADWW <br /> 7,Tran"por(er 2 Company Name ,s.OA i Nwrber <br /> 8 Deslgwtgd F861ety Name and Site Meas U,5.EPA ID Number <br /> INC.Il� ry a <br /> . _ CAt880 ,418 <br /> N <br /> Faa-Yt a Alrona: i17 . <br /> ga 9b US.DOT Oeadrhtlan Qx1 np Proper&hlpptr g Name Hazard Clsas,ID Number, 10.OgRkklera .. i1.Tainl 12.Wt 1�tArata Gbdea <br /> NM and Padang Group(If my)) Na. T1Pe Ltls�dly <br /> 0 1 HYAZ WUS V"TF9=tD �,PET'NCLEiltra <br /> l <br /> Y # •/ <br /> Uj <br /> ra <br /> 3. <br /> 4. <br /> L—L± I <br /> • nding Insbtto na AftlTnedorl <br /> ERG 71461 # <br /> i6 N6flA7OlC8rOrF!ROR'8 CERTIFICAtION:f he eby degigra that itis gontgnla of fs corxrtgnmarn are <br /> III <br /> a deecrt sbtwe by the propershlpping nerve,and ore dasOad,pad*ed, <br /> marked 8nd labak�dfptacerded,and are lr all mapeo%In proper condgon for transport addetdbg to OKIM to a netk)rO repuletiara.If a+Wort atdpment end I Am the Primary <br /> Fdtpottor,I oar*dtiat the oonlenls d tlis consignment conform ro N!amts of the"tlaohad EPAA*)QWedgmsrA of n <br /> I oarty ki the waste minImbAl n ststamer;Idsvfte A 40 CFR 28227(s)(H I am a loge M amts,gest"or(b 1 smelf q I;;Vffatcr le true. <br /> Citlrlere erors f§bftedlf Natna L, Slgnatttracal Year <br /> 42112 <br /> - <br /> QlmprntMU,S. ❑Expart4'ornU.3. gFe:rLyl�di:. <br /> Tranapartoralgnature{bcrt»gaorteanlyl: � leavingUS•, <br /> V.Tran Pw*AcWft edpmaM of RaQ*of Ma4,,els <br /> Trinupartet1 yped ems signature 0 ear <br /> ranapo n ��� t3lgrtebrre Mardh E* Year <br /> � 18.Dlspepen6y ''''t1 <br /> 18s.Dlwsperiq Indicahn SW Querray Ett--_ITypo J Reeld a U ParBal Rootd 0 Full Re]"dlcn <br /> i <br /> I RAmnoa <br /> 18b,A ngta Fs^(cr Generator) U.S.EPA 10 Number <br /> � i <br /> cs <br /> rQi reciva Phone: r <br /> ,� Bo nature ofAmirraw Fadety(or Q ; Oay Year t <br /> moo <br /> 1 Hazerdous Ytneste Reload ManapameM Method Codes(f.e,,codes for hm rd=weele uwtmard,d"I,and rocyding <br /> 1. s <br /> aI <br /> I`T I' <br /> t <br /> 20.DgWrwIed Fa^owner or Operator,CarttBcsdon of recd pt of hmarddua mefadal8 Deeded by Bre m r aat except as rwAad In kale 1k'I t <br /> Name 5)greAee <br /> oa 1290 1 r <br /> EPA Form 670x22(RW.UO Pmv)eus GdMons are obsolete. NAPE[):FAgI;ITY TO,DE5't1NAT10N STATE(IF gpaUl <br />