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<br />Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 2050-0039 4 GENERATOR ' I U N I F 0 R M HAZARDOUS
<br />WASTE MANIFEST
<br />1. Generator ID !slumber .. ,
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<br />2. Page 1 of 3. Emergency Response Phone
<br />4441.13C*0
<br />4. Manifest Tracking Number
<br />00 33 •,?.„ r.-.; 669 JJK _
<br />Generators Name and Mailing Address,' .: -7. -17 . , ,
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<br />Generator's Phene: , _3,7
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<br />Generators Site Address (if different than mailing address)
<br />Transport4r,thilaartrtyroritnetrol 5 irvicros r---, 7--' . • U.S. EPA ID Number
<br />' 1 CAD9a241:,,M2
<br />Transporter 2 Company Name NOV 1 7 2008 U.S. EPA ID Number
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<br />Designated Facility Name and Site Addresskii4algreen On, frte. ENVIRONMEN I HEALTH U.S. EPA ID Number
<br />6$430 ;:lrnith Ave, PERMiTISFROCI=S
<br />Newark, CA 04560 CAD9808-r4 1 II
<br />Facility's Phone: !,1 04'725440() I
<br />ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit
<br />HM and Packing Group (if any)) .. No. Type Quantity Wt.Nol. 13. Waste Codes
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<br />14. Special Handling Instructions and Additional Information - .
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<br />15. GENERATOR'S/OFFEROR'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 lam a large quantity generator) or (b) (if I am a small quantity generator) is true.
<br />Generatort/Offetor's Printed/Typed Name Signature Month Day . Year
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<br />16. International Shipments , Import to U.S. Export from U.S. Port of entry/exit:
<br />Transporter signature (for exports only): Date leaving U.S.: TRANSPORTER 17. Transporter Acknowledgment of Receipt of Materials
<br />„ Signature .._ .," Transporter 1 Printed/Typed Name .4 Month, Day Year.,
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<br />Transporter 2 Printed/Typed Name - Signature , Month Day Year
<br />I I I I DESIGNATED FACILITY 18. Discrepancy
<br />Discrepancy Indication Space LII Quantity LI Type LI Residue LI Partial Rejection LI Full Rejection
<br />Manifest Reference Number:
<br />Alternate Facility (or Generator) U.S. EPA ID Number
<br />Facility's Phone: I
<br />Signature of Alternate Facility (or Generator) Month Day Year
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<br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
<br />1. 2. 3. 4.
<br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a .
<br />Printed/Typed Name Signature Month Day Year
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<br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY
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