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* *Generator, Mail a copy to: DTS" P.O. Box 400 Sacramento, Ca. 95812-0400 w,,nIn 30 days.* <br />Plea-") pdrit or type. (Form deslqned for use on elite (12 -aitch) tvoewriter.) Form Approved. OMB No. 2050-0039 <br />EPA Form 8700.22(Rev.3.05) Previous editions are obsolete, i:AG1'•_I*l'Y 1'0 (I: <br />UNIFORM HAZARDOUS <br />1. Ge ( ID Number <br />� <br />2. Page 1 of <br />3. Emergency Res $a Phone <br />4. Manifest Tracking Number <br />0 0 7038898 <br />JJ K <br />WASTE MANIFEST <br />(��,;;27C'0- <br />1 <br />1.804.424-9300 <br />5. Generators Name and Mailing Address / Generator's Site Address (f diNerent than mailing address) <br />. G SLS/f3�o�J <br />X14 14� . <br />eG nerdtors Phone <br />6. Transporter I Company Name <br />U.S_ EPA ID Number <br />EVERGREEN ENVIRONMENTAL SERVICES <br />CAD982413262 <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8. Des.gnated Facility Name and SileAddress Evergreen 011, Inc. <br />U.S. EPA ID Number <br />6880 Smith Ave. <br />Newark, Ca. 94560 <br />CAD980887418 <br />Faatys Phone: 510-795-4400 <br />9a. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12, Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (d any)) <br />Ouantily <br />Wtivol. <br />1. <br />z <br />W <br />2. <br />0 <br />— <br />- <br />— <br />3. <br />r <br />I <br />4- <br />14. Special Handling Instructions and Additional Information <br />15. GEN ERATOR'SfOFFEROWS 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 labeledlpiacarded, and are in a9 respects In proper condition for transport according to applicable International and national governmental regulations. It export shipment and <br />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 minim%zation statement Identified in 40 CFR 26227(a) (d I am a large quantity generator) or (b) (if I am a small quantity generator) Is true. <br />Generatas'OfferoesPrintedrT Name Signa, <br />Month <br />Day Year <br />-.i <br />F— <br />16.Intema' al Shipments ❑ rt S. P text <br />Import to U.S. po <br />Z <br />Transporter slgnature (for exports only): ate leav ng U.S.: <br />LW- <br />17.Transpo(ierAOu)oWedgmentofRecelptdAlatedais <br />Transporter 1 Printed/Typed Name S gn <br />Month <br />Day Year <br />CL <br />CO <br />- S' <br />Transporter 2 PrintedlTyped Name Signature <br />Month <br />Day Year <br />H <br />18. Discrepancy <br />18a. Vscrepana Indication Space ❑ quantity ❑ Type ❑ Residue <br />❑ Partial Rejection <br />❑ Full Refection <br />Manifest Reference Number, <br />18 b. Alteinale, Facility (or Generator) <br />U.S. EPA ID Number <br />J <br />U <br />LL <br />, <br />Facility's Phone: <br />LOU <br />18c. Sgnature of Alternate Facility (or Generator) <br />Month <br />Day Year <br />Q <br />Z <br />V519. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and reading systems) <br />0 <br />1. <br />2. <br />3. <br />4. <br />�ily DA ner or Operator. Certification of recelpl of hazardous materials covered by the manifest except as noted in Item 18a <br />Signature <br />f nth <br />Day Year <br />EPA Form 8700.22(Rev.3.05) Previous editions are obsolete, i:AG1'•_I*l'Y 1'0 (I: <br />