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Please print or type.(Form designed for use on elite(12-pitch)typewriter. F-�'5 3 Form Approved.OMB No.2050 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CALOM025654 1 800424-9300 004907563 JJ K <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> LORI HONDA <br /> 1700 S.CHEROKEE LAME <br /> LOOT,CA 95240 <br /> Generators Phone: ' <br /> 6.Transporter 1 Ccmpany Name U.S.EPA ID Number <br /> EVERGREEN ENVIRONMEN'TA.L SERIACES CADSIF2413262 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> PHIUP WEST INDUSTRIAL SERVICES& CAF000177So <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Nuumbbe, <br /> 21 ST CENTURY,EMI NV 980895 139 <br /> F�NEwILANDS DRIVE EAST <br /> .NV 894M <br /> Facility's Phone: 775-575-2760 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,!D Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> w <br /> TIM coo <br /> 2/1 <br /> 3 <br /> W 2 <br /> Z <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> PROFILE/Tia t3 ERG I Z DFUM SIZE: <br /> 15. GENERATOR'SlOFFEROR'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, <br /> 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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity gene t )or(b)(if I am a small quarility generator)is true. <br /> Gener to s/Offerors rinled/Typed Nema Sign Month ay, 1 <br /> r c <br /> 16.1,emalior I Ship ents <br /> ED i- Import to U.S. l.. <br /> r_I Export from U.S. Pert 10 eniryiexiC <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> U 17.Transporter Ack ment of Receipt of Matenals <br /> Transporter 1 PhntedTlAd Name Signature Month Day' y <br /> 0 Z� <br /> Z T rter n ted/T Name Month Da 1 <br /> Q <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity ❑Type1 I <br /> E]Residue Par' Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> rai Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day <br /> H <br /> Q <br /> Z <br /> in19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1. 2. 3. 4. <br /> 20.Designated Facility Owner or 0 rator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature +nth_ Cay <br /> =o e z- � � 'l P� � lJ CC` C <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACIL4�Y TO DESTINATION STATE(IF REQUIR <br /> f) n9-09A.-9.49 R C V D <br />