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NOV-21-200T 06:53 FROM-EVERGREJ INC. 510-791-0126. T-303 P.003/003 F-226 <br /> Please print or type.(Form designed for use c elite(I h)lyp-writer.) <br /> 1 crater ID Number , Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS Cir -.Page 1 o1 3.Emorgoncy Response Phona =4, rat Tractane Number <br /> WASTE MANIFEST // 1 1-800-424-930 ,58 g 6 ,�J @C <br /> 5,Generator's Nnme and Maillnry A dro- - Generalor's Silo Address(if dlitardnr than meJing A(.IreSs) <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S,EPA D Number <br /> Evergreen Environmental Services CA)982413262 <br /> 7.Transporter 2 Company Name U.S.EPA D Number <br /> B.Designated Facdhy,Name end$0.Aildfeos evergreen OII, U.S,EPA D Number <br /> Inc. <br /> 6880 Smith Ave. <br /> Newark,CA 94,560 <br /> Facility's Phone: 510-795-4400 C/'i]980887418 <br /> gal 90.U.S.DOT Description(including Proper Snippktg Nomu,Hazard Class,ID Number, 10.Comalnrrs 11.Total <br /> HM anti PBCkiny Group(ii any) 12.Un t) No. Type Quantity wl.Nol. 13 Wasic Codes <br /> 2. / <br /> CD j I <br /> 4, <br /> 14.Special Hanoling Inslrucllons ar)dArldili(mLil Intormalion <br /> 770/1 <br /> 15. GE14ERATOR'SrOFFEROR'S cERT1FICATION; I harecy declare that the contents of this consignment aro fully and areurlluly described above by lbe papal snipping name,ar I are clir;sifed,packaged, <br /> markc-d Lina labaluc/placardod,and are in all respects In pruper condition for transport according to applicable inturnalionatana national oovarnmontal regufabe t.II export shipment and I am the Pan+:lry <br /> Exporter,I certify that the contents of into consignment conform to me terns of the otlach(:d EPAAcknowlodgmenl of Consenl. <br /> I ceriily[hat Ire waste minimization statement i0n1l6d In 40 CFR 262.27(a)(if I am a large gvan111Y generator)or(b)(if]em a snlah quontity generator)iss true <br /> Garlerdlorsl0flerofs Printud/Typctf Na a Slgntaurc Month h9y Yuar <br /> Ldw. r7 <br /> _.I 16.Intarnallonal Shipments 0 <br /> Import fo U.S. ❑Export from U,S. Port of ontrylexit: _ <br /> — Transponai signalure(for exports only): Dale leaving U.& <br /> p= 17.Transporter Acknowl dgmenl of Receipt at Mbleduls <br /> uu <br /> Transposer 1 PrlMi pen N:+me <br /> f Signarura �' a A4onth Day yam <br /> lTrarlsDAer2 rinse pea Nam. $Up1+ rc Month Day Ycar <br /> t- <br /> 18.Discrepancy <br /> 18n,piserrpamy 6icbcatian Spacu � quantity ❑Type <br /> ❑Residue Q Partial F a)echon ❑Full Rejection <br /> I+aanife5l Rcloronce Number. <br /> 18a.Alternate Facility(or GOerslur) U.S.(:PA I( Number <br /> C.? <br /> Facility's Phone; <br /> W 18c.Signature of Ahernare Facility(or Generator) <br /> ¢ <br /> rolth Day Y'esr <br /> 2 <br /> cn 19.Hazardous waste rtepoil Msnragorriunl Molhod Codes(i.e.,codes for hazardous wrrgle trtalmuni,disposal,and recycling syslern5) <br /> LU <br /> 1' 2. 3, <br /> , fly l 4. <br /> 20.Designated Facility Ownsr or Opernlor;Cerl[rication of receipt of hazardous materials covered by the manifest excopi as nttod in Ilem 18s <br /> Prinle4rryptu Noma Signalure Month Day Year <br /> 61"". rk<J2-Z--k l p°r <br /> FPA Porm 87D0-22(Rev.3.05) Previous editions aro obsolete. DESIGNATED FACILITY TO DSSTI 4ATION STATE(➢F REQUIRED) <br />