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NOV-21-2007 08:53 FROWEVERGRE M INC. 510-791-0126 T-303 P.002/003 F-226 <br /> !ctGelterator, mall a capY to: 11 ­%4+v-,-1 P11--u --._ -._- —• - Form Approved.UMa No.zUbU-UUatJ <br /> Please print or typo.(Form designed for use on elite(12- )typowritec) <br /> t 2 Pa <br /> G Sic 1 0l 3.Emrrgency Response Phonu 4.Manit at Tracking Number <br /> UNIFORM HAZARDOUS . dralor ID Number <br /> WASTE MANIFEST � �'� �' � O i)2 5 8 6 9 5 0 JJK_ <br /> 5.Gensralor's Name antl Mailina Address Generators site Address(If N1lerent[hail mailing so Tress) <br /> Geherator'sPTtan : y� / � l- �s� f <br /> EPumb <br /> 6.T sorrier 1 Comp Name U.S. GA�D er�� ry <br /> vrgreen nvtmnmental Services <br /> U.S.EPA D Number <br /> 7.Transporter 2 Company Name <br /> B.Designated Facility flame and Site AddrEssEvergreen 011, Inc. U.S.EPA ID Number <br /> GM Smith Ave. <br /> Newark, GA 94OW <br /> 5110 79s-4.400 c kQl 7��$ <br /> Facility's Phone: <br /> gb.U.S.p0T OnIAPlron(incluchng Proper Shopping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unil 1 i Waste C00's <br /> go 0uanuty yvt.Nol. <br /> HM rind Packing Group(if any)) No. Type <br /> 2 <br /> W _ <br /> C9 <br /> 3 - <br /> a. <br /> 14.Special I9Snollno Inslmctlons and Adoulonal Inlorm3110n <br /> 15. GENGRATOR'SIOFFEROR'S CEFITII'ICATION; I hereby declaw 1113:the contents of this consignment are fully and accuraloly descrlbea abovc by Iha pre ter shipping name,ani ore classified,p3chsged, <br /> merited and labeleolplMadEc.and arc in all respects in proper condition for transport according to opP)Icable Imannallonal and national governmental rogdl Vons.If expon chlpmenl and I am rhe Primary <br /> Exporler,I cerlify that the contunls of This conslgnmanl conform 10 The terms at the attached FPAAcknQWledglnenl of Consonl. <br /> I canify Ilial Irk waste nmllmhslion stalement idenlirrud in 40 CFR 262.2713)(if I am a large quantity generator)or(b)(If I am a small qu 1ny gene or)is 'us ldonrh Day Yaar <br /> Go ioew"ffarcr' Print y oo Neme Signal - <br /> � <br /> J 1fi.Imerna onal Stlipmenis import to U.S. ❑Expon from U.S,'11. emry/or<II: <br /> Transporter signature qor exports only) Dato loaving U.S.: <br /> V.Transporter Admawle r11 of Receipt of Materials 2 <br /> Transporter 1 Prime Na Signature Monthlkez' — } Day Vear <br /> Prinladff ed ldamc Sign re n1h Day a <br /> 4 Transpol yP <br /> >w <br /> OC <br /> 1B.Discrepancy — rr'' <br /> 18a.Discrupancy Indication Space Ouam y ElType ❑RasidUe ❑Pa Al Rejection I__I FSU Rejoclion <br /> Manifest Reference Nurttber: <br /> 'I Bb.Allemato 1`10iry,(or GomrTilor) U.S.t PA ID Numbvr <br /> Facility's Phonc: Month 03y ye3t <br /> LQ 1So.Signature al Alternate pnciiity(or Gonor3rar) <br /> 4 <br /> z <br /> 19.hazardous Waste RapOrl Mansgemont Method D0CI8S(I e„codes for T Azerdous w2Sl�treatment,Glsposal,and rocycling systoms) <br /> UJ 1 z g. 4. <br /> a <br /> 20.0esignalud Facility Owner rn Operator:Ccrtilicallon of rocoipl of nazardoas materials covered by the manliest except as ndod In Item 18a <br /> Prlmetl/fypcd Nmne Siflnalvre C-,Jl� Month Day Year <br /> EPA Form 8700,22(Rev.3-0F) Previous editions sre obsolelo. DESIGNATED FACILITY TO DE STIMATION STATE (1F REQUIFIE1 <br />