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ternAPPrOved OMB No. 2050-0039 (Expires 9-30.94) arsto Instructions on oacK or P090 6. <br />Pluzna fprirn or Form designed for use an aft (12-pikh) typewskor. <br />%o UN <br />(FORM HAZARDOUS 1. Generators US EPA ID No. Manifest No. 2. Pop 1 <br />® WASTE MANIFEST c L Q O U o U ®� Q 0 of j <br />3. Generator's Name and Mailing Address <br />PAC lr (c COAST PR.oDul <br />in 5L/ So. SrOCx.TON ST <br />otn 4. Generator s Phan iz (,ni) 339.33-Sj LU D r 1 C A qS' t.i lf <br />d 5. Transporter 1 Company Nome 6. US EPA ID Number <br />L�55 EVERGREEN ENVIRONMENTAL SERV.C DI I 9 7 <br />7. Transporter 2 Company Name B. US EPA ID Number <br />U <br />® U.S.P.C.I. i T X1 DI 918181 <br />LOQ 9. Designated Facility Name and Site Address 10. US EPA ID Number <br />Z U.S.P.C.I. T.R.S. y <br />M ® 1021 Berryessa Road <br />Department of Toxic Substances Control <br />California <br />Information in the shaded areas <br />is not required by Federal low. <br />tV u San Josei, CA 95133 1 C A D A 54 i 13 11 <br />M Z 11. US DOT Description (including Proper Shipping Name, Hazard Class, alNumber) 12. Corn►aihens 13. Total 14. Unit <br />No. T7T-,,,, Wt of <br />3 G NON RCRA HAZARDOUS WASTE SOLIDS <br />N E 60 DIM 0Uv5' G <br />Go N b. <br />•} E <br />C4 R <br />T C. <br />a R <br />LU <br />Z d <br />W <br />U ' <br />Q <br />Z <br />Q 14. Spacial Handling Instructions and Additional Information <br />Z Wear Protective Clothing 24 Hour Emergency Contact -Kirk Hayward <br />= DOT Guide Book #31 Emergency Telephone # - 1-510-795-400 <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 />Q packed, marked, and labeled, and are in all respects in proper condition for fronsport by highway according to applicable federal, state and international laws. <br />V <br />If I am a large quantity generator, 1 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 />a 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 />y1 threat to human health and the environment; OR, if 1 am a small quantity generator, I have node a good faith effort to minimize my waste generation and select the best <br />waste mans ement method that 's available, to me and that I can afford. <br />Q Pr11 ints y d "i /J Signa►urs A Month Day Year <br />Uk <br />71U <br />f :r <br />Z <br />i <br />17. Tron66orter 1 Ac Howled e - oi'rof-Moteriak <br />0R <br />a, <br />s <br />Prints Typed Name Signature Month Day Year <br />v�i� o22iSa N <br />w <br />® <br />316iqi3 <br />Wa <br />18. Tronsoorter 2 Acknowledgement of Recei of Materials <br />U. <br />I <br />Printed/Typed None <br />Signature <br />Month Day Year <br />O <br />Is <br />wt/1 <br />19. Discrepancy Indication Space <br />U <br />A <br />Z <br />C <br />® <br />I <br />1 1 <br />1 <br />20. Facility Owner or Operator Certification of recei t of hazardous materials <br />covered by this manifest except as noted in Item 19. <br />TT <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />DO NOT <br />/y.. WRITE BELOW THIS LINE. <br />Blue: GENERATOR SENDS THIS COPY TO DISC WITHIN 30 DAYS. <br />DTSC 8022A (7/92) To: P.O. Box 400, Socromento, CA 95812-0400 <br />EPA 8700-22 <br />