Laserfiche WebLink
SEP-23-2009 09.06AV FROM-EVERGREEN OfL 510-791-0126 T-917 P.002/003 F-032 <br /> r <br /> please print or type.IFarrm daslgned(or use on elite Farm Approved.pM8 Na.2050.0039 <br /> UNIFORM IiAZARD0U5 1, eWiforlA Number Z.pa e 1 of 1 3.Emergency Response Phpne S.ManlinsaTrackfnq Numbof <br /> WASTE MAKIFEST Zof -8'aU424 000899463 JJ K <br /> 6,Ganerswr,6 Nama end Mallkb AWlroes Generators SheAddross(f differs I th0n malling address) <br /> Gonoratore PhanoG "r <br /> U.S. 413262 <br /> s.T"45WEAffitorurlenta! Services- , <br /> 7.1rinsponer 2 Cow ny Name U.S.EPA l0 NumDer <br /> K. <br /> DasIgniJeJ Fedlhy NyrM and Ske Address Ve1'gl'een 00, nr.- U.S.EPA ID Number <br /> 6W Smith Ave. <br /> Newal#r CA 945W <br /> 510-7954400 CA7418 <br /> FaC�lryS Phonu: - <br /> no. go.U.S.DOT Doserlpfloo�induding Proper Shipping Name,Harard Class.ID Numper, t0,CQntalnars 11.You l 12.knit 13.Waule Codes <br /> MM and Packing Group(II any)) <br /> No. Typo E]uan9ty WtivQi. <br /> tr <br /> ur <br /> z 2. <br /> LU <br /> 3. <br /> 9. <br /> i q.$peclel HanCltng InslNctians and Adtllllpnal Irltomrasbn <br /> r <br /> 15. C,ENEFZATCRISIQFFEROR'S CERTIFICAPON: I hereby doelare Thal Ina conlente of tNr consignment aro Idly and arp,r8lely described above by Me proper shipping name,am are etessifred,packaged, <br /> marked and labeledfplecardod.and are In eB reepocls In proper condidon for Dema on according Io appuraDle iniamet uwl end naliorrrl governmental regyations.11 export srllpment and I am the Pilmery <br /> Exaormr,t caNFy that the contents al Ws consignment conform la Ina teens of the,Sheched EPA Acknowledgment of CQRanL <br /> I Canlly tM9l the waste rrinknhaWn slelemeni Identifled In A0 CFR 292.27(s)(If I am a large quentuy generator)or(h)(If[am mall lor)r{rub. <br /> GeneralarelolfororS PrintedfTyped Name Signature !Month Day Year <br /> 15.It%emotlonel ShipmonlSPort Q11enlrylexiL- <br /> ❑Import to U.S. ❑E-1W Irani U.S. <br /> Transportrstgnatura(forexporlS OW; Dale loaving U.S,: <br /> W 17.Tfaneporter ACkn wI0Q9 t of Race pl of Matariek <br /> cn <br /> T <br /> ransporter 1 FrinW T me Slgnawre Month i}ay Year <br /> 76 2 P rledfryped rn4 Sk1n ro CL tvknln Day Yo3f <br /> Ia.DlsQapancy r—� <br /> 1 Be.olscrupancy inbicetlon Spada ❑ Quantity U Type ❑Raddue ❑Penial Ro}ucllon ❑Full Rojecdon <br /> Manliest Relerenb4 Number <br /> lab,AIIQmeta FwIlGaneram¢ US.EPA 1D Number <br /> ly fvr <br /> J_ <br /> U <br /> t4i Facllitye Phonu: <br /> Month pay Yoar <br /> � 1gt.SlgnaSuro olAhernala FaClliry(a Genbrltlor} <br /> 19.flazarocus Want@ RapM Man19amenl Mothod C44e9(I.e.,codes for hazerdat'S Waste treeimont,Wspbsel,and rouyCll tg eyelems) <br /> !4l ( I <br /> 20.Deslgnabed Fatlihy OrWner of oporrnlor.Ceriilltallon of receipt ofhonrdoue.matonala covorud by the manifest excapt es nded In Isom I Be Month pey Yaur <br /> peered TypeQ Name 5 <br /> EPA Form 9100-22(Rev,3-05) Pravbus adilione aro obsolete. DESIGNATED FACILFFY TO DESTINATION STATE(IF REQUIRED <br />