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EC-26-1991 11:17 FRIDrifJ Jrti�iJIN LUMBER.re or Califon,-, Health and W911111Agency TO 464[138 <br /> roml Approved OMB No.zaso�3p(£_vpires 8•SO.g t} ' - P-02 <br /> Please prim or type, fx` r d"sn" d lo"US@ 01 elhe 12• Department of Health <br /> ( imera ypewIDE Tax Department Substances ComroSDvsion <br /> UNIFORM HAZARDOUS GB ie e,l;.US EPA ID No. Salemomd,Cal@Drhi@ <br /> WASTE MANIFEST Ma^ileat 2. Paye t <br /> 6 9 5 7 6 I1 men/ey M I I is not ohm a by Federal <br /> I.,r <br /> 3. <br /> Gen WASTE <br /> Name and Malting Address is not redulred by Fetlerei law. <br /> EYERGRCr!ti ENVIRONIME14TAL SERVICES ! til�c.I 7^ L ''I-IL. A. State Manheai em Number <br /> saga smith Averupt, Newarit, CA 94W ; lf�, r I 856 07493 <br /> al a. G01161A If Phone( 415 795-44.10X414 Zty IS_ w 8. State Genes.",.IH A <br /> D <br /> c+�u <br /> i,ii6. Tranaponw 7 Company Name C. . .I. e. a a 14 40 4 <br /> dba EVERGREEN ENViFON. US EPA ID Number G Stat@ Tran 7 <br /> Gm`4 S G d D 3 E 0 apo tesla to O/ <br /> 7. Transporter 2 C Ma^Y Name 6�9 5!7 6 ]. 0. Transported Phone _ <br /> O S. US ePA ID Number <br /> oz E. State TransDOrlwa ro <br /> A. Dorsi{mated pp"'Jiy Name and 511 Address I F' Tre^eRwter'a Phone <br /> EVER^REEN ENYfRON;-4L%TAL SERVICES US EPA 10 Nambw <br /> G. State Faclllty's ID <br /> T� CAD980S457 $ = <br /> CAD 91,$- - H. F.cluya Phone <br /> 40 6 9 6 1 (MM 9724! <br /> 11. US OOT Deacr on ncleding Proper Shipping Nema.Hazard-183S.and 1D NumDer) t <br /> Pti D Containers 13. Total. 14, <br /> �Vunit <br /> .. '1. <br /> 1�-,� .. No. I Type Ocam,fy Unit ' ;Waste No. . .. <br /> N P Nos, CCMBUMSLE .. .. .. . Wt/`vol <br /> _ NA Iz7o> rRLEu>N ons. uQuro, _ <br /> E b. O ()1 11TIT <br /> A <br /> A <br /> T '"' V State _ <br /> T R p, EPA/Other _ <br /> F State <br /> Q <br /> d, EPAIONer. <br /> 2 _L) I I State .. <br /> W <br /> rat J Addpbnal Dever EPArgAw -. <br /> S Ipfloida for Materials Lilted Above I'{I <br /> K. Heltdlinp Oodea for wastes Listed Above ' <br /> mss,.. V�frl�wR�ai7rfl '+, a. b. <br /> 1.2 •awi+'�.3aMw! ,max,. 3' <br /> Y" C. <br /> 15. Special Handling Inatrueliens ane AdditinbaI Infermafien <br /> i Wwr PrOtecdvB CbtRiag <br /> J <br /> J 18. <br /> .% GENERATOR'S CERTWICATION: I h <br /> e cor, <br /> ri and are claasirld,pecked.;narked,and labeied,a tl serer vii re en's of ihle canaglanem ere fully and accuratei descri <br /> I - --.•iatlorwl govwnmem regajig; tor_ _ —. .__ spare in proper condition for transport by hianwey acc7rdinaabove <br /> o e by Amro a Imametlonel wM 1 <br /> it l am a I@ryo Quantity - <br /> to be a,AMr,;csl p practicable I certNY that I have a r ." ".. +....,..._r„�.;,;.,�y.- <br /> N hreati toh u and Mat I neve aeleetsd IM pryCtitablo meth!of Meatmem,sterape,or dispesai eartenl. avaflo to me which minimizes fate' <br /> program In place to reduce the d0lume and toxicity of waste generated;o the degree(Aare determined <br /> Present end future tNeet to flumen AeaRh end the environment;OR,it I am a small Quantity generate.I have meds il good lahh effort to mlMml:e <br /> general and select the best rest,rano <br /> it,mem method thdt is available.0 me end that I Can Bill¢, my reatB <br /> Printetl:Typetl Name <br /> "i <br /> Signature <br /> Cf_.�aT ! Month Day, Year <br /> i R 17 Med <br /> Trenepw 1 Acting yemwn of ReoerP,of materials J~ _ I " - <br /> N C/TYPe¢Nam, <br /> S S•y f ytu <br /> P I VVIR y MBNA Day Yesr . <br /> i O 18. Tranep w 2 2 AEknprlpdgempm of R <br /> R eceipt of Materials <br /> T ' .Pfmt>C/Typed Name <br /> E.a: _:� .. Slure <br /> " I <br /> 7Month Day YSar 'Y <br /> 9. Di!4eparrcy Irgicy M Space <br /> F IF� 1 <br /> �.�.kov1� M .J.X.virt Vt ►4 <br /> ./1 � C�•/f 14►-ado` . <br /> Nod w��d� 1 i <br /> T '- 2a. Fecilry Ormer or OPen 101 CartNltai{pp pot r : <br /> Y Prmtad/T ecelpt o1 AaurtlOae materials eovereb by thio manifest ea0epf p flptCd in kem 19. <br /> yPad Name <br /> Signature <br /> 9077 A(1/aa) Mdnffl Day yNr <br /> 8700—22 Nor Write Below <br /> 9.88}Previous itions are obsolete. TI1i5 line <br /> ed <br />