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K <br /> Please punt Of type,(Palm deslgnod far use on elite 12- Ify ,pewriterEES-4 Form.) Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOU5 1,Genorotor ID Numb r 2.Page 1 of 3,Eme ge�cy Response?hone 4•Manlfast Traeking Number <br /> WASTE MANIFEST _ 002587179 JJ K - <br /> 0•Gose olv NJ and Molting Addrocc Ganeratcrs 51tA Address(if different Than mailing address) <br /> C <br /> !1 i a �o uTH c h s r►Ice� t•w�-•� <br /> Lo-a; Co 9J-.AVO <br /> Genornlor•s Phone: - d <br /> fi.Transporter 1 Compx+y Name G.S.E'A(D Number <br /> EVERGREEN ENVII�O MENTAL SERVICES CAD982415262 <br /> 7.Transporter 2 Company Name U.S.EPA t0 Number <br /> B.Daslgnatod C Vt Sia 11GGI�dUTL, <br /> IN U,S,EPA ID Number <br /> 6880 SMITH AVENU CAD980687418 <br /> NEWARK CA 94560 <br /> roollitys Phone: <br /> Oe flb.U.S.DOT Descd iInJ i 6• ht ping Name,Hazard Class,ID Number, 10.Containcrs 11.Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(if any)) No, Type Quantity WLNoI, <br /> ON-RCRA HAZAC'0C0;IJ':S' <br /> WASTE, LI UID 1 TT <br /> LU <br /> 2. <br /> Q <br /> 3. <br /> 4, <br /> 14,Special Handling Instructions andAddltlonal Information <br /> PROFILE # tib'' INVOICE INvo1cE # 5�/�?9p <br /> DOT ERG#171 WEAR PROTECTIVE CLOTHING SALES ORDER #1,TY6,Pr <br /> 15- GENERAT0R'5/QFFER0R'S CERTIFICATION: I hereby declare that the contenta of this consignment are fully and acouratoly described above by the proper shipping name,and are d3asified,packaged, <br /> marked and labeledlplacardod,and ars in all rasp4cls In proper condition for transport according to opplltable Intemational and nalionoi governmental regu'abons,if exportahlpmant and I am Uro Primary <br /> Exportar,I certify that the contents of this consignment conform to the terms of the attached FPAAcknevAedgmenl o!Consent. <br /> I certify that the wasto minlmlzati'on statement Identified In 40 CFR 252.27(a)of 1 em a large quantity generator)or(b)(if I am a Smell quantity goaerator)ie true. <br /> Generator's/OfloroPs PrintedfTyped Name <br /> Signature Month Day Year <br /> 16.Internet omtl Shipments to U. • LJExport from U. . P5/of ontrylexlt: <br /> Transporter signature(for exports only): Data leaving U.S.: <br /> w 17.Transporter Acknowledgment of Rocelpt of Matsdais f <br /> I nature "xonih—Day—�Yoar— <br /> Transparler 1 PrinteclDged Nome / 8'�, <br /> Or2 r0 <br /> 2 Transporter 2 PrintedFryped Name <br /> ig <br /> Snature Monfh Day Year <br /> 18.Discrepancy I�1 ;I <br /> 18a.Discrepancy ndi;xtlor.Space OTyPe n Residue ❑Partial Ro)eclion LJ Pu i Rc!,o l n <br /> ❑ Quangty <br /> Manifest Reference Number. <br /> ll.S.EPA 1D Number <br /> I el;,Alternate Facility(or Generator) <br /> J_ <br /> C:7 <br /> •t4 FecilitVs Phone: Month Day Year <br /> w 18c.Signature of Allemalo Fa91lty(or Generator) <br /> Q <br /> Z <br /> 19..Hszerdous Wn_ste Report Managoment Method C es(Le.,wdos for hazardous wEt;te treatment•Qlsposel,end rccyding systema) <br /> a 1 2. <br /> 3 4. <br /> 20.Designated IFadllty Owner or Operator.CatficaUon of receipt of hazardous materials cmored by the manifest except as ndod In Item 113; <br /> Signature MonUr Day �Ye�ary <br /> Pr,nlcdlfypeQ Nemo fry l <br /> /IC RPf]r IIRG111 <br /> 171-d 600/100 d 968-1 0886 VVI 019+ HAON 30IA63S d3HO1SnO N336JHA3-MdO ftEZ: H 8001-91-d3S <br />