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Please print or type (Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No,2050-0039 I. erator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Man Tracking Number UNIFORM HAZARDOUS 4 . WASTE MANIFEST 5:Generator's Name and Mailing A dre�s Generator's Site Address(if different than mailing address) erattfone � U.S.EPA ID Number e.Transporter 1 Company Name AD 8 1326- Evergreen EnVIMPIMental Services U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number ' 8.Designated Faciiity Name and Site AddressrI �R Inc tiewark,CA 945W CC; Facility's Phone: WO-796-4400 9a. 9b,U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 1 z 2 UJI 3. 4. 14,Special Handling Instructions and Adolf onal Information _ "" �.✓✓ Pze - 15: GENERATOR'SIOFFEROR'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, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable International and national govemmentai regulations.if export shipment and I am the Primary Exporter,l certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent, I certify that the waste minimization statement identified In 40 CFR 28227(x)(If I am a large quantity generator)or(b)(ff I am a small quantity generator)is true. Month Day Year Gane ralOfferor s Printed/Typed Name Ig ( r" � 18.Intemationai�hlpmenta �Import to U.S. ❑Export from U:S, Port of entry/exit; Transporter signature(for exports only): Date leaving U.S.: 17.Treneporter Acknowiedgme t of Receipt of Materials th Day Year Tr nsporter 1 PrintedlTyp me S(gneture Mon " Transporter 2 P ed yped N e nature th ay Year 18.Discrepancy 18a.Discrepancy Indication Space Quantity I21ype ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number., 18b.Alternate Facility(or Generator) U.S.EPA ib Number J U Ili Facility's Phone: C.Signature'of Me mate Facility(or Generator) Month Day Year R a 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 3. 4. 1.. I2,t M.DesignatedFacility Owner or Operator:Cartification of receipt of hazardous materials covered by the manifest except as noted in Item 18a anted ryyped Name signature Month . Day Year EPA Form 8700-22(Rev.3-o5) Previous eations are obsolete: DESIGNATED FACILITY TO GENERATOR