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**Generator,Mail a copy to: DISC P.O.Box 400 Sacramento,Ca.95812-0400 within 30 days.*" <br /> Please print or type.(1'cxm dr:sl}pied for use on elite(12-pitch)lypowriler.) Form Appmved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Rosponss Phone 14.Manilest Tracking Number i <br /> WASTE MANIFEST l �aeQ� � 6SIS� 1 800-424-9300 1 008643599 JJ K <br /> 5.Gunemlat'a Ntunn and MaChm eVdress t e <br /> r�encmfor`s Sile Addreos ill dinewso Ih:or m Jlhrn addnss) <br /> Gmtornlots Phono, <br /> U.S.EPA ID lurmhir <br /> G.Transpoder 1 Company Name <br /> Evergreen Environmental Services Cbgp982413262 <br /> 7.Trampurlef 2 Company Name U.S.LPA ftl Number <br /> 8,DorlgnaGvl Facihy Nance and Sita Addrase U.S.EPA ID Number <br /> Evergreen 011,Inc. <br /> 6880 Smith Ave. CAD980887418 <br /> Newark,Ca.94560 <br /> Ftfl(t .,More: r <br /> 9a 9b.U.S.DOTDescrlption(ncluding Proper Shipping Name,Hazard Cluse,ID Number, 10.Conlalnem 11.Total 12.Unit 13.Waste Codes <br /> HM and Packlag Group((#any)) No. Type Quantity M.Nol. <br /> fleAl upZ <br /> 3. <br /> 4. <br /> 1.1.SpackdHnn llnfllnstructicnsOrd Addifonallnforreuliun <br /> 15. G'ENERATOR'810FFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully end accurately described above by the proper shipping name,and aro classified,packaged, <br /> marked and labeledlplacarded,and are In all respects In proper condition for transport according to applicable International and national governmental regulations,If exportshlpment and I am(he Primary <br /> aportor,I cerlify Ihal the contents of[his consignment conform to the terms of the allachad EPAAcknowbedgment of Consent <br /> I certify that the waste minlmizalbon statement Identified In 40 CFR 282.27(a)(If I em a large quantity generator)or(b)(HI am a smal quantity generator)is true. <br /> Goneraloes/Dfleror's Prl !Typed Name Sig lurekloolh Day Your <br /> AA-A <br /> !t f 1/li (A <br /> W 1A <br /> —1 166matione Shipments Import to U.S. ❑Exporlfrom ItS. Port ofentrylexit <br /> Transporter signature(for exports only): Date leaving U.S <br /> n' 17.TrensporterAdmowledgmantofReceipt o(Materials <br /> Sig S vudr z Month Day Yerr <br /> � Trcrrsprnto i PrinterYi'ypod Name <br /> A <br /> Transpotlar 7.Priated/Typed Nam Signature Month Day Year <br /> 18.Dlsorepancy <br /> 18a.Discrepancy Indication Space ❑ Quanll ly f f ❑Residue ❑Partial Rejection ❑Full Rejection l' .o <br /> Wmilest ReNronce Number: <br /> 18b.Altema(u Facility(or Generator) U.S.EPA ID Mirabor <br /> L<L. Facllhy's Phone: <br /> a 18c.Signature ulNlornalo Fn*y(or Ganernlw) Month Day Year <br /> Z <br /> 19.I luzard xs Waste Report Prknnngwuert Method Codes(Le.,codes for hazardous waste treatment,disposal,and recydtng sys(orns) <br /> 0 1. 2, <br /> 20.Designated Fadllty Owner or Oporelor:Carliiticatbn of rocalpt of hazardous materials covered by the manliest except as noted In Item 18a <br /> Prnladfryped amu ggnatufn n8) �Day Ynar <br /> LPA Fnnn 8700-22(Rev.3.05) Pfovlous. Ilion are obsak:l©, ( -�'XEDACILITY TO DESTINATION STATE(IF REQUIRED) <br />