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• <br />0 <br />PI' t e (Form designed for use on elite (12 -pitch) typewdler) <br />Fan Approved, OMB No. 2050-0039 <br />ease <br />pnn or up . <br />UNIFORM HAZARDOUS <br />1.G a ID Number <br />ZPege l of <br />3. Emergency Response Phone <br />4. Maniksi TmcNing Number <br />0 6 612 41 JJ K <br />WASTE MANIFEST <br />- �`� <br />1 <br />1-800-424-9300 <br />0 6 <br />5. Generalces Name and Mailing AddressAy r�r__„��„�c�Genaralors Site Address (if dl6e�lhan mailing address <br />dto-9 �lrf'✓�GiS/f�/°' ��z/,k-�. l'�J - g5—"v?jo <br />Generalofa Phrme:a3.s'c3/ <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Evergreen Environmental Services t CAD982413262 <br />7. Transporter -2 company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address Evergreen 011, Inc. U.S. EPA ID Number <br />6880 Smith Ave. <br />Newark, Ca. 94560 CAD980887418 <br />Facility's Phane: 510-795-4400 <br />ga <br />gb. U.S. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Tabd <br />12 Ung <br />13. Waste Codes <br />No. <br />Type <br />HM <br />ing <br />and PacGroup Of any)) <br />Quantity <br />WN/ol. <br />1. <br />0 <br />Z <br />Z. <br />W <br />C7 <br />3. <br />k <br />4. <br />14. Special Handling Instructions anclAddltional Information <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare [hat the contacts of this consignment are fully and accurately described above by the proper shipping name, and are dass0ied, packaged, <br />marked and labeledlplscarded, and are in all respects in proper copdeon kr transport according to applicable International and national governmental regulations. lexicon and I am the Primary <br />Exporter, I certify that the conlenk of this consignment conform to the terms of the attached EPAAdurowledgmenl of Consent. <br />I ceAry that the wash mimmimmin statement identified in 40 CFR 262.27(a) Of t am a large quantlty, genemter) or (b) (til am a smati quantity generator) Is true. <br />Mamh Day Year <br />GenemmeslONemfs Printed Name Signature11V EX El <br />LII t <br />r <br />18.Indema[ioual Np <br />Impodte U.. ❑Fxpad fmm PM of enhyladC <br />z <br />Transporter signature (for exports only): Date leaving US.: <br />C <br />17. Transporter AdmoWedgmedofRecootofMali <br />th Day Year <br />Signa Mon„ <br />O <br />Transportert rotName <br />�! <br />4 Trensponar2 Pdntedrryped Name Signature Month Day Year <br />} 18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Padkl Rejedfon El Full Rejeal <br />Manliest Reference Number. <br />U.S. EPA 10 Number <br />156. Alternate Fadfty (w Generalorj <br />J <br />C) <br />u Faciktys Phone: <br />18c. Signature of Alternate Facility(or Generator) Month Day Year <br />Qw <br />2 <br />(D 19 -Hazardous Waste Management Method Codes (I.e, codes far hazardous waste bea6nant, disposal, and recycling systems) <br />/Re�poorrt <br />2. 3. 4. <br />20. Designated Facility Owner or Operator. CeNtication of receipt of hazamous makda[s covered by the manifest except as noted in Item 18a <br />Pdnledrryped Name Slgnakre Manch Day Yeer <br /><50 <br />EPAForm 8700-22 (Rev. 3-05) Previous edigbns are obsolete. DE'StErFjATED FACILITYTO DESTINATION STATE (IF REQUIKED, <br />