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DTSC. 08082 . 00;73 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) ` Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page i of 3.-Emergency Response Phone Manifest Tracking Number <br /> WASTE MANIFEST C4 0 r 72 2 93 1 1.8 4.00-424-9300 001819870 JA <br /> 5,Generators Name and Mailing Address Generator's Site Address(d different than mailing address) <br /> yCT✓L VSA <br /> r)r-0^ek,)A5e_ c� <br /> Tri► C& S.r77 <br /> Generators Phone: - <br /> 6.Transporter 1 Company Name U.S.EPA 10 Number <br /> EVERGREEN ENVIRONMENTAL SERVICES CAD982413262 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.DesigttFglyTT[ttWooAdJZ. U.S.EPA ID Number <br /> 6880 SMITH AVENUE <br /> CAD980887418 <br /> NEWARK CA 94560 <br /> Facility's Phone:510-795-4400 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity W"Vol. 13.Waste Codes <br /> 1' ��d UdTGr <br /> 0 NON-RCRA OUS WASTE, LIQUID 1 TT G <br /> z 2. <br /> Lu <br /> 3. <br /> 4. <br /> 14,Special Handling Instructions and Additional Information PROFILE# <br /> INVOICE#37YYS'f <br /> DOT ERG#171 WEAR PROTECTIVE CLOTHING SALES ORDER# fcV 71 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labelediplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(d I am a small quantity generator)is true. <br /> GeneretorslOfferoes Printed/Typed Name Signature Month Day Year <br /> C�->~t� �2� C s�Nr�2 /z o 06 <br /> -J 16.International Shipments <br /> I- ❑Import to U.S. ❑Export from U.S. Port of entry/exit <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> IX 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter�tpeyped Name Signature Month Day Year <br /> y i L 12�// �- /Z- 1 0 od <br /> Z Transporter 2 Pdntedfryped Name Signature Month Day Year <br /> cc <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity El Type El El Partial al Re1ection Full Rejection <br /> Manifest Reference Number. <br /> 18b.'Altemate Facility(or Generator) U.S.EPA ID Number <br /> V . <br /> Facility's Phone: <br /> L- <br /> Z <br /> 18c.Signature of Alternate Facility(or Generator) _? Month Day Year <br /> l- <br /> Z <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1. � I ` 2. 3. 4. <br /> 20.De-q'gnaYed Fadefi ( r or Operator.Certification of receipt of hazardous materials covered by the manifest except <br /> Pdnted/Typed Na Signa Month Day Year <br /> EPA Form 8700.22(R v.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 00027.1546 <br />