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OTSC. 01048. 2471 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter) Forrn Approved.OMR No.2050-0039 <br /> UNIFORM HAZARDOUS 1. neratc ID um r 2.Page 1 01 3.Emeryenry Response Pnorce d.Manttest Tracking Number <br /> WASTE MANIFEST 1 1-800-424-9300 0 0 2 3 9 0 29 6 JJ K <br /> 5.Ganarao's Nameam Mai lin ��� h_-yam Generators Site Address(if different than malting address) <br /> (,Y-ze" I�(2 <br /> 0 o X/O �'-di-ti <br /> G9�y33g3 mow . Ps�/9 <br /> 6.Transporter 1 company NameU.S.EPA ID Number <br /> Evergreen Environmental Services CAD982413262 <br /> 7.Transposer 2 Company Name U.S.EPA ID Number <br /> S.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Evergreen 011, Inc. <br /> 6880 Smith Ave. <br /> Newark,CA 94560 <br /> Facifl a Phone: 510-795-4400 CAD980887418 <br /> pia 9b.U.S.DOT Description(including;Proper Shipping Name,Ha l Class,ID Number, 10.Containers 11.Total 12.Unit 13.waste <br /> Catles <br /> HM and Parsing Gray(8 aryl)it Wk �y /� No. Type Cuamy WlNol. <br /> /'r'"' yy �Pi1 t� V <br /> 2. <br /> W <br /> 3. <br /> 4 <br /> 14 Special llan/dliQg lnauctions andAiddonal Informa�tlon6y/ <br /> 15. OENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately deal above by me proper shipping name,am are ciassifled,packaged. <br /> marked and Iebe soacimil ,am ere in all respecis in proper condition for transport according b applicable Internacional and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I witty that the contents of this consignment cordial to the temp of the atleched EPAAcknovdadgment of consent. <br /> I ciall that the waste minimization statement identrad in 40 CFR 262.27(x)(81 am a large quantity generetN)or(b)(if I am a small quantity generator)is he, <br /> Genera rslOffemre PdnmdR Name 'S re Month Day Year <br /> n o9 <br /> J 16.Internal Shipments <br /> F- ❑Import to LLS. ❑Expos ham U.S. Pa mrylexit <br /> = Transporter signal(for exports only): Data leaving U.S.: <br /> W 17.Toempol Acknoolmem of Recall of Materials <br /> Transported Pdn Name Sgnawre MmorDay Y <br /> 6 <br /> < Transpon 'er2 tWff d ame Signa Monty Day Year <br /> C <br /> r <br /> I <br /> 16.Diwapanq <br /> 18a.Discrepancy Indication Space ❑ Cul ❑Type ❑Residua of ❑Ful Ra <br /> ❑Partial R action jecign <br /> Mal Reference Number <br /> 181p.Atlertlats Facility(or General U.S.EPA ID Number <br /> J <br /> 0.a <br /> LL Facil Phone. <br /> W 18c.Signature of Alternate Facility(or General Monro Day Year <br /> H19.Haowdas Waste Report Management Method Codes(i.e..codes for haradous waste aeatmaal disposal,and recycling systems) <br /> G 7 HIL � 2. 3. 4. <br /> 20.Designated Facility Omer or Oxfam r Cer6flraton N receipt N lazardous matenals covered by me manifest exapl as noted in Item 18a <br /> PnntaMyped Name Sgru Month Day Year <br /> -s'Ica-e <br /> EPA Form 8700-22(Rev.3-05) Final editions are obsolete. NATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 10585.0356 <br />