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State'of California—Environmental Protection Agency <br />i! Form Approved OMB No. 2050-0039 (Expires 9.30-99) <br />lease print or type. Form designed for use on elite (12 ewriter. <br />O <br />ko <br />LO <br />f\ <br />CN <br />LO <br />00 <br />acv <br />C <br />C% <br />b <br />c <br />C <br />a <br />09 <br />LL <br />H <br />Z <br />LL <br />U <br />LL <br />V. <br />C <br />V <br />LL <br />a <br />o. <br />u <br />ae <br />C <br />U <br />z <br />•' LL <br />L <br />09LL <br />LL <br />LL <br />C <br />LL <br />V. <br />a <br />2 <br />See Instructions on ba age 6. Department of Toxic Su6stgnce: <br />Sacramento; Colifornic <br />(� DO NOT *KTE BELOW THIS LASIC. <br />N <br />1 • Generator's US EPA ID No. Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />UNIFORM HAZARDOUS <br />is not required by Federal law. <br />` <br />WASTE MANIFEST b <br />of 1 <br />S4 j <br />3 General s N and Mailing Address <br />,`� <br />A. State Manifest Document Number <br />-226740:•8 <br />1/70 f F/TE- fi <br />a�°hc <br />B. State Generator's ID I <br />4yr° n e (2�09 I y4 k.X?31 <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C: State Transporters ID -[Reserved.) <br />l: <br />EVERGREEN ENVIRONMENTAL SERVICES <br />CA0982413262 <br />D Transporter's Phone <br />8009724284 <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />-E. State Tronsporter's ID [Reserved.] ; <br />F. Transporter's Phone, <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G State Facility's ID <br />EVERGREEN fill, INC. <br />D 9 9 Ifl 1818 I T I Q 11 16 <br />6; H., 'Facility's Phone. I <br />6880 Smith Avenue <br />Newark, CA 94560 IC JA D 19 18 10 18 18 17 14 1118_ <br />(510) a9s-4400 <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />Quantity <br />14. Unrt <br />Wt/Vol <br />.I, Waste Number <br />No, <br />I Type <br />i2 <br />�Stater <br />I , <br />G.9 <br />WON-RCRA HAZARDOUS WASTE, LIQUID <br />®1 <br />T T <br />G <br />EPA/Other ' 1 <br />1 <br />E' <br />N <br />6. <br />State <br />I. <br />E <br />EPA/Other.- <br />R <br />I. <br />A <br />c. <br />stole <br />T <br />1. <br />® <br />EPA/Other i- <br />R <br />d. <br />Stote, <br />EPA/Other <br />{ <br />J.; Additionol:Descriptions For, Materials listed Above <br />K. Handlin Lodes for Was <br />9; <br />Listed:Above <br />15. Special Handling Instructions and Additional Information 7(Q <br />�, 0 / <br />24 Hour Emergency Response Telephone No.: CHEMTREC 1-800-424-9300 Invoice I 4 <br />Sales Order I �1 d`�T <br />DOT ERG 171 - WEAR PROTECTIVE EQUIPMENT <br />16. GENERATOR'S CERTIFICATION: I herebydeclare that the contents of this consignment are Fully and accurate) described above by proper ship ing name and are classified, packed, <br />g y i <br />in for transport by highway according to applicable international and notions government regulations. <br />marked, and labeled, and are in all respects proper condition <br />If I am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economica <br />and that I have selected the practicable method yarn <br />storage, or disposal currently available to me which minimizes the present and future threat to humanlheo <br />practicable <br />and the environment; OR, if l am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best waste management methodithat <br />available to me and that I can afford. <br />Pyntefl/Typed NameSignator <br />? <br />Month' Day j <br />2 G <br />T <br />I7. ns iter 1 Acknow ement of Receipt of Materials l <br />R <br />Pri ted yped Nam <br />Si <br />to <br />R <br />/onth <br />I <br />2eipt <br />0 <br />18:, Trans rter 2 Ackno�IedWemeloof'Materials <br />T <br />Printed/Typed Name <br />Signature <br />Month Day 1 <br />E <br />R <br />19. Discrepancy Indication Space I <br />F <br />i <br />A <br />I <br />C <br />' <br />I <br />t <br />i <br />L <br />( <br />20. Facility Owner or Operator Certification recei t of hazardous materials covered by this manifest ce t a noted i m 19. I <br />T <br />Pri a pod Nome <br />Signator <br />Month Day <br />Y <br />r. <br />(� DO NOT *KTE BELOW THIS LASIC. <br />N <br />