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"Generator, Mail a copy to: DTSC P.O.Box 400 Sacramento,Ca.95812-0,VQn3iMIr0p fta,.*t 8 4 9 <br /> Please print or".(Form designed for use on elite(12-pitch)typewrler.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.GenealorlD Number 2.Page 1 of 3.Emergency Response Phone 4,ManBes[TackinNumber <br /> WASTE MANIFEST /�z73�s-� , 800-424-9300 008612791 J J K <br /> 5.Generators Name and Mailing AddressL Genemtofs Site Address(B different than mailing address) <br /> Generators Phone: <br /> 6.Transporter 1 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.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Evergreen OII,Inc. <br /> 6880 Smith Ave. CAD980887418 <br /> Newark,Ca.94560 <br /> Faotlitys Ph": <br /> gra 91b.U.S.DOT Desoipbon(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12 Unit <br /> HM <br /> and Facing Group(if any)) No. Type Quantity WINO, 13.Waste Caries <br /> � 1/VBw/,1G1+'�R' BrsS l�Sj�) LlfY>itJ <br /> zzj <br /> 3. r <br /> 4. <br /> 14.Special Handling Instructions and Additional Information / ` / 7/ � ti �i(2C -'W—/ <br /> 96_Z 7V-z ; 7/ !�6-2-- <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of the consignment are fully and a¢uatety,described above by the proper shipping name,and are classified,parhaged, <br /> marked and labeledlplawded,and are in all aspects in proper condition for tramped according to applicable intema8onal and national governmental regulations.tevpon shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached FPAACIaovAedgmenl of Consent - <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b)(if l sm a small quantity generator)is bus. <br /> Geneatofs/Offemfs Printedyr Name Signature Month Day Year <br /> -s 16.hinternatemal Shipments <br /> F ❑ImpM to U.S. ❑Expo U.S. Pat of enhylexit <br /> = <br /> Transporter signaNre(for exyorlsanly): Date leaving U.S.: <br /> W 17,TansporterAclmomedgmentof Receipt of Materials <br /> O Tanspater 1 PnntedlTyped Name S Mantn D� r <br /> z)t -- 3 <br /> QTransporter 2 Printedrryped Name Signalua Month Day Year <br /> K <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Spars ❑ auamay ❑Type ❑Residue ❑Penal Rejection ❑Full Rejection <br /> 44.p/— W4,—/a RBCL-IJ a 0 A-r.'Vn/7R4 3, WR57C Ft�AVL1 Qr,ti oS,�-AS.iia (W47E2 wrT-q 6 rsxr..e) <br /> —571zVol Polk, nffesl Reference Number. <br /> 18b.Alternate Facility(or Generator) _.. ;s is F3A,ID(Jhmh6ez; <br /> J <br /> U n <br /> LL Faciliys Phone: JAN 19 JOIR <br /> W 16c.Signature olAltemate Faality(or Generator) Month Day Year <br /> Q <br /> 2 <br /> H19.Hazardous Waste Report Management Meted Codes(1..0.,cod%low hazardous waste treatment deposel,and recyclingsystems) <br /> 1 11st / 2 )7(1-1 / 3 ._r4 <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item I Be <br /> PnmtetllTyped Name Signature Month Day Year <br /> 103106 11.1Z <br /> EPA Form 8700-22(Rev.3-05) Previous abitionsamobsolele. GNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 11136.1970 <br />