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"•Qenerator,Mall acopy to: DTSOP.O.Box'400Sacramento,Ca.95812-0400 within 30 days.'"" <br /> Please Itlor trades ned for use on elite 12- itch)ly writer. 102 Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 2.Pagetof 3.EmrgemyReapwa Phon4.Manifeal eakRiNumo <br /> WASTE MANIFEST LW% Wc �/ 800.424-9300 008542748 <br /> JK <br /> 5.Gamesome Namse McINg aeaa'J'„yjJ tjdjjJf souGAildre [lfdl%ranithan Ingaddrms) <br /> C,emmWapk <br /> 6.Transporter I Company Nam U.S.EPA ID Number <br /> Ever reen Environmental Services CA0982413262 <br /> 7.PampererCarryeny Nene U.B.EFA ID Norman <br /> a Designaledfac Namean SileAddess U.S.EPAIDNumber <br /> Evergreen 011,Inc. <br /> 6880 Smith Ave. CAD980867418 <br /> Newark,Ca.94560 <br /> Faci BFhona Al Q-Mq-44fln <br /> ya 9b.U.&DOT Oeedpllan(mtluding Pmper6Npping theme,Hazard Gam,ID Numwg 10.ConhMe!e 11,Total 12.Unit 13.Waste Codes <br /> RM and Packing Gmup Rarnol N. Type QuenEty WWoI. <br /> ,d <br /> o tiVa9A1l �9 aA/v�Jdrt�Gl �Ii:� :� v!/ LAY R <br /> �3 <br /> C� <br /> 3 <br /> 4. <br /> 14.2peaaN1andItrat lmuuctlom2mAddlronal mmmlat)an „��. ,/,A / _�7/ ��yr mys�y�•9a,3� <<s"a.S— <br /> 16. GENERATOR'SWFFEROKSCERIIFICATION:I horebydedaegtatlheconlenle of this ranslmetenl erefJlyamlaaureteq dewtibed abambythe pmpershlppot;name,and are dasslged,packaged, <br /> meMed wA IrbslagpMwMed,end are In ellrespecte In properwndigw fartrenspat acooMng h epplica6le Ydemallonelend na'we1 gwemmantJ regJetlws.if expudshlpmort and I am the Pdmery <br /> Expolar,I certifythal tiro contents otims mnvgomant oamrm to the term ofthe afthed EPAAaknoaladg Cant of Consan L <br /> Ica"Nat the wash ninImizatlon:MtemeNIdentified In 40 CFR 26227(a)(W I am a large quans6 generator)or(b)(6I am asmall qua (sgenom,or)is too. <br /> General gmotS PrlJe dName Igne re Month Day Year <br /> 1-4� 2 1113 <br /> iQ lnfame6wa9 1pmens <br /> F ❑Import b 1.S, EVd Wm U.S. PcdWenlryfa <br /> Ttampoderaignahae(Tor e wry): Datelo"ng <br /> V.TmnspomkincwdodgmanlofReceldofMatuals <br /> � mnspot rn y oma SI r. - Month Day Year <br /> 0. <br /> aTmmporler2Pmedflkced N8am - S!gnauue MmIl Day Year <br /> 16.Diemepamy � 1 <br /> III&DlscmpancylMiwgon5tmw Llowtty El Type ❑ma-'dus ❑Psuds R.P,11n LJ FW Re)amian <br /> Molest Refa me,Number: <br /> 166.AJtemete PazAry(wGewmbr) U.S.EPAID hFm bar <br /> Q <br /> u Fgdys Phoma <br /> 16n Skinalum 01AVermie FaWity(or Gammatar) Monih Ney ear <br /> 13.Hazardous1. Waasto RRe <br /> 7eportMamgemw (t MettwdCodes A,cWma for mzoMouswaah ImaimeM,disposal,and recycling systems) <br /> 11,81gmted FaeftO,ynerwOpamtw CeJAsaWn ofmcelptofheretleus mandate oammd by the manifest exceptea noted In Item 183 <br /> PdriedlPiped Norte Slpnahre Month Day ser <br /> ie � 15 r <br /> '. ,.,IPAFam a70N-28(Rev,3405) FravioutInoditIons are obsclela APED FACILITY TO DESTINATION 3TATE(IF REQUIRED) <br />