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• <br />EVERGREEN ENVIRONIOENTAL SERVICES <br />State <br />Form <br />of tolifernia—Environdlental Protection Agency <br />Approved MB No. 20584039 (Expires 9-30.94) <br />See Instructions on back Age 6. <br />Department of Toxic Substances Control <br />'Pleas <br />IS.o Form designed for use on elite (12 -pitch) typewriter. <br />Sacramento, California <br />UNIFORM HAZARDOUS <br />1 • Generators US EPA ID No. Manifest Document No. <br />(y '340 <br />2. Page 1 <br />Information in the shaded areas <br />is not required by Federal law. <br />Newark CA K60 i <br />WASTE MANIFEST <br />11. US DOT r- r <br />'`f (! % <br />I �7 <br />ofi <br />vR*FAa*W <br />a <br />• <br />3. Generator's Name and Mailing Addressa <br />b. <br />. <br />NOR -RC ';iO <br />h <br />e4 LI I <br />n <br />C14 <br />4. Generator's Phone00 <br />t <br />5. Transporter 1 Company Name <br />6. US EPA ID Number <br />• <br />EVERGREEN ENVIRONIOENTAL SERVICES <br />r <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />9. Designated r US EPA ID Number <br />Newark CA K60 i <br />11. US DOT r- r <br />e i tt� <br />vR*FAa*W <br />a <br />• <br />b. <br />NOR -RC ';iO <br />t <br />13. Total 1 14. Unit <br />mm©0mnmmw <br />0 15. Special Handling Instructions and Additional Information <br />aWearRubtarGloms 24 hour emi ergency rinporroa 510-795—WD Emergericy cnnaet-Kdtk Hayward DOT Gul <br />Z <br />W_ <br />H <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of the consignment are fully and accurately described above by proper shipping name and are classified, <br />packed, marked, and labeled, and are in all res m proper condition for transport b highway according to applicable federal, state and international laws. <br />Q P P� � P P P Y 9 Y 9 PP <br />U <br />If I am a large quantity generator, I certify, that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be <br />economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future <br />CL threat to human health and the environment; OR, if I am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best <br />N <br />waste management method that is available to me and that I can afford. <br />0 Printed/Typed Name Signature Month Day Year <br />Z T 17. Transporter Ac owe ement of ecei t of Materials V <br />WR <br />0 NPlrm� /Typed Name Signature <br /><W 5 .•• <br />G P <br />o -,•18. rens rte; 2 Acknowled ement o Receipt of Materials <br />LU T Printed/Typed Name Signature <br />U- E <br />O R <br />w 19. Discrepancy Indication Space <br />V) <br />Q F <br />U A <br />Z C <br />I <br />L <br />I 20. Facility Owner or Operator Certification of receipt of hazardous materials covered b ti <br />T Printed/Typed Name Signature <br />Y <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A (7/92) <br />EPA 8700--22 <br />(, .✓ Month Day Year <br />�... 0 1 �t 21 4, I '11-b <br />Month Day Year <br />I I I I I <br />Month Day Year <br />Yellow: GENERATOR RETAINS <br />