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Please grin',Tor tree. {Oim1 designed for use on elate 02-pi,dt) typeun'.erJ EES -4 <br />Q-TSC,ORSS6.OS97 <br />Form Approved. UMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions areoosolete. VtIGNATED FACILITY TO DE INATION STATE (IF REQUIRED) <br />10320.1422 <br />UNIFORMHAZARDOUS <br />1 1. Generator I0Num`�er <br />'b <br />2.Pagelof <br />1 <br />3.ErnayencyResporsePhore <br />1-800-424-9300 <br />4.ManifestTracking Number <br />1 003779015 JJ K <br />WASTE MANIFEST <br />D'j 0 <br />ene atzfs Mane and laingkdress / Generatets S 1eAdd'ess (1 diferenl an ma" address) <br />�. <br />S'-// S' ft.4p7r%1 rat. lZ, rpt c %La s /v •�4.1� c4t %Za3 <br />Generaloes Phon . / r Z •-- 7- <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />6. <br />Evergreen Environmental Services CAD982413262 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Des'gnar Fad , Name z eAddress <br />r U.S. EPA ID Nu ber <br />Veteen Y, Inc. <br />6880 SMITH AVENUE <br />NEWARK CA 94560 CAD980887418 <br />Facility's Prone: 510-795-4400 <br />oa <br />•9b. U.S. DOT Decxip•7cn (hcfud6y Proper SWpping Name, Hazard Class, ID Numter, <br />10. Ccir ainers <br />11. Total ' <br />-12.UM <br />13. Y7as'a Codes <br />No. <br />Typa <br />H!,1 <br />and Packing Gmup (1 e rj)) <br />Quarty <br />1St h'cI. <br />o <br />!NON-RCRq- HAZARDOUS WASTE, LIQUID <br />LZ <br />5 <br />001 <br />Ti' <br />G <br />Uj <br />2. <br />w <br />C7 <br />3. <br />4. <br />14. Special Hankin :g InsLvctohs and kddi*nal tnforma]. » <br />P ROFILE..# INVOICE'S �fJ,�ysl <br />DOT ERG# 171 WEAR PROTECTIVE CLOTHING S14LES 0 DER.# <br />,+i�Z.7 <br />15. GEN ERATOR'SIOFFEROR'S CERTIFICATION: I herebydedaro that re cen'en's cf Ws amsgrrranl are tl'y and accuraleydesctbed atare by the proper ah'pp'rg nacos, and ar`e dassifed, pz624rJ <br />marked and tabe'ed'ptacarded, and are In at respects In proper cond *�on for transport eccor fJ g to apprcaNe Ln erradonal and natcnal govenursn'al regulators. If export sh pmem end t am the Primary <br />bporter, i certify that the contents of this ccnsigw.enl cmform to the terms of the etleched EPAA0AorMedgment of Consent <br />I cer5ly that the vrasle rrinlmhaton statement Iden0ed in 40 CFR 26227(a) (.11 am a large quantioy genera!or) or (b) (i11 am a smal qua ,. generator) Is' e. <br />Generatofs 0fi rces Ptntedlfy Name Sgnalu e IAor.th Day Yew <br />'eV w .. o y y lot <br />1 <br />16. Intema[onal Sh Amens <br />❑ import to U.S. ❑Export from U.S. Plef'entryleyl <br />Transporterslgnatuta(forexportsorJj):. DarigU.S.: <br />w <br />17. TransporterAc rc6lWgmenl of Rctxyl of hlatedals <br />Transporter <br />Prntedffyped Name' ` S gnz erre <br />a MAnth Day;, Year <br />a <br />D� <br />Transporter 2 PMtcdfTyped Name Slgnayr, Monih Day Year <br />N <br />18, D"screpancy, <br />18a, Discrepancy Indra,on Space rn, ❑ T ❑ ❑ ❑ Fu0 R,jecten <br />❑ Quan" ype Residua Par'dai Re;'ec5on <br />PhAfest Reference Number. <br />J <br />18b.A1'emateFaa:tj(or Generatu) U.S. EPA ID Number <br />U <br />LL. <br />FecTtys Phono: <br />W <br />f 8c. Sfgnatura of Monate Facily (or Genera!of) <br />hlofM Day Year <br />t— <br />Z <br />N19. <br />Hazardous Ylasia Report Management Method Codes [.e., codes for hazarVous waste treatmert, dsposal, and recyo:ng sys'ems) <br />LU <br />1. <br />2. <br />�� <br />T- <br />20.Deslgna'ed Fao:y Omer or Dper'.cr. Ce .fcafon of receipt of hazardous ma'efas covered by N man fest except as acted in Item 18a <br />4 4 <br />Prk teaTyped Name S'gnahea M.on h Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions areoosolete. VtIGNATED FACILITY TO DE INATION STATE (IF REQUIRED) <br />10320.1422 <br />