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pleas$PAn(uryPe. orFRreeslgnedwrgsa °8i{; 5rc�;�1�-IRAT4111 dalrstt.. <br /> Form Approved.OMS No.2D a$q <br /> UNIFORM HAZARDOUS 9. aisle 1 Namber 2.Page1 of 3.Emergency Response Phone' " 4.Manlfear Tracking Number <br /> WASTE MANIFEST <br /> 5.Generemla Name and Mallinp Ad r t n ` ""'� � 0 0 2 58 6 990 9 0 JJK -' <br /> /I99G(ICo syi�y oG�f/� �a , Generators&W Addmss(f different Nan coshing addrn5) <br /> Gananlnft Phma:' � ,�� <br /> 8.Transporter 1 Company Name <br /> T';Evergreen EPvilvnmenta:.Services . . :... ..:: :.:.. ... .,w. :,,.,::. <br /> U PA ID Number <br /> CAD9MIA1.3262,; <br /> 'Treers'pOitfF 2 Corhpany Name U.S:EPA ID Number <br /> S.Designated Fadllry Name and Site Address EU.S.EPA 10 Number <br /> :, kergreen Oillnc..: <br /> NeWa`f)t'!CJl <br /> Fac S P ne: <br /> it, 9b•U.S.DOT Deacripbon(mduQrg Proper5hfpping Name.Hazard Clear,ID Number, 10.Confers 11.Tate1 12.UnS <br /> HM end Parking Group(d any)) No. Type 00FALY WL/Vol, 19.YVaste Codes <br /> Ix <br /> s1 c3dT C /�X6�/C ic/ �r <br /> UU 2. ^, Z a�U✓Lt/, � <br /> jr,Orv. ��f L�idS7ei�i8 7.a-- <br /> uvG� u a�7c c 2, 1 fv O <br /> A. <br /> 14.Spedel HerCing msWcdona ondAddifional In omlaUon <br /> /7 <br /> — / 77 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: 1 hereby declare that me Contents Cf This consign enl an filly am aeCVgley deswM0 above by the Droperahlpping name,and are clemlhed,pooeaged, <br /> marked and IabeltNpliarded,and are In all respects in proper ConGNon for 7anepoft according to ap0loable Intemadonal and national govemmsnlal msula50nS.It export Shipment and I am the Primary <br /> Elpor ,er,I cylNy Met the coolants of this consignment conform b the terms of the enarhed EPAAckn Medgment of Consent. <br /> I ceNyMet thewaste minimization ablement IOendUed inAb CFR 26227Ia)(d I am a large quantity generator),oc(b)(KI ama$mall quanary.generator)iaWe....__........ <br /> GenereN,/JslClrtrols PdntedRyDed Namep Signature <br /> MorNf Dal' Year <br /> 1E Mbms5onal Shipmema / dr <br /> x ❑Impel to U.S. ❑Z pre from US. Pon of enaylexit: <br /> Transporter signature(for expone only): Date leaving U.S.: <br /> 17.7mnsporterAdn _ ant of Reeelpl of Materials <br /> Bf ranspoler 1 do d Neme Signature <br /> p Monde Day You <br /> Z Tamopone nob yped amed <br /> S MonUr Day Year <br /> }. 12.Discrepancy . <br /> 18a.D screpancy Indication Spew ❑ puantity ❑ I--� <br /> 'I`/pe Residue I�Partial RejeWon ❑Full Relecdon <br /> iSb.AUawte F2GTy(or Generator) Manifest Rebrenw Number. <br /> US.EPA ID Number <br /> U, <br /> Fao711ye Phone: <br /> ray 16e8IgnaWre ofAllanao Facilly(or Generator) amn ay nr <br /> N <br /> 9.Fb2aroous-YJaatIReDOM1MOM9emen4Method Codab(:a,codaafoFlfaaallods•Walla.trHbnNtrdbpoealrand requ irgaystems).- <br /> Wo 1 2 9 4 ..:... <br /> Pill !—�I'f i Nly I - <br /> 20.Deelgnaled FadOry Omer or Operator.0#40oafkm of receipt of hauakus materials cwemd by the manifest exeapl as noted In Item 12a <br /> Pdnledfryped Name J� naMre Moth Day Yeu <br /> �•�� %"tor�� �'�-- OS 1 ..7 07 <br /> EPA Form87D v.3-0b) PreviduBedMonsareahsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br /> ZOO 'dKV 6580 119 01OZ-LZ-Mv <br />