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(Forrn designed for use on elite(12,pftch}typewriter.) FarmARp roved.OMB No.2050.0038 <br /> .rr Va HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Ernergency Response Phare 4.Nlarrrfest Tracking Number <br /> WASTE MANIFEST CAC98014M 1 800-4249360 1004907765 JJ K <br /> 5.Generator's Name and_Mailing Address Generator's Site Address(K dtffererd than marling address) <br /> J R SIMPL.Oi <br /> 16777 HOWLAND ROAD <br /> LATHROP,CA 953301 <br /> Generator's Phone: 209-858-2511 <br /> 6.Transporter i Company Name U.S.EPA ID Number <br /> EVERGREEN ENVIRONMENTAL SERVICES CAD982413262 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Desi ated Faci iHty Name and Site Address U.S.EPA ID Number <br /> lERGREEN Q)LJNQ CA[ 7419 <br /> 6880 SMITH AVE. <br /> NEWARK.CA 94560 <br /> Fac k fs Phone: 510-795-440 <br /> ga. 9b.U.S.DOT DesaipUm(rndtnfirtg PruperShippbrg Name,Hazard Class,ID Number, 10.Cardabmers 11.Total 12.Unit 13.Waste Codes <br /> HM and Paddrq Group(d any)) ti r. Na. Type Quantity WLAU. <br /> Ax <br /> 00 boot --wigT <br /> 'Z 2 j G� <br /> /bob <br /> L.; 3, <br /> 4. <br /> 14.Specal Handling Instructions andAck itronal Information <br /> PROFiLEA /r DRUM SIZE: <br /> �Y y X370 y,�Z �/7/ <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consi9ffrot are fully and accurately described above by the proper shipping name,and are dasd&ed,packaged, <br /> marked and Iabaladlplacardad,and are m afl respects in proper omr[dtimn for transpod somrdmg to aWicahle intamationaland national govemmenW regulations.gexport 9*m*rd and I am the Primary <br /> F_>Wrter.I certify that the contents oniric wnsEgnment conform to the farms of the atlarhed BIAAdmadedgment of <br /> I certify that the waste minimizatlon statement idendf[ed In 40 CFR 262.27(a)(ff 1 am a Image 4oardity germerator m a nlity generator)is true. <br /> Gen rors PrtntedlT d Memo- ' S" Month Day Year <br /> Q i 0 1 127 102 <br /> 1 16.International Shipments <br /> F ❑Import to U.S. F-yortlrom U.S. Port of enfrylezii: <br /> _ Transpmrtersignature(for exports only): Date leaving U.S.: <br /> W 17.TransporterAcknow] of Receipt mf MatNWs <br /> t2 Z <br /> r 1 Printedff are Stgnature Mo Day Year <br /> �// �7 a <br /> ar yped Name 6ne Moro Day Year <br /> 18.Discrepancy <br /> 18a Discrepancy Indic0an Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejecrmn ❑Full Rejection <br /> Manifest Referenm!dumber. <br /> 186.Altemate Facaity(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> U< FadliVs Phone: <br /> W 180.Stgnatoe ofAltemale Facirdy forGermerator) Month Day Year <br /> Q <br /> z <br /> 9 19.Hazardous Waste Report Management Method Codes(l.e.,codes for hazardous waste treabnenl,dimspOsal.and recymling systems) <br /> G 1. ]2- 3. 4. <br /> 20.Designated Facility Owner or Operator:Cer0Cation of recoo of hazardous materials covered by the manifest except as noted In Item 18a <br /> Printedlryped Name Stgnahrre Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous edlkons are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />