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onmentol Protection Agency <br />�6 No. 2050-0039 (Expires 9-30.99) See Instructions on back of page b. Department of Toxic Substances Control <br />ry"pe. Form_designed for use on..elife.(12-pitch) iter. ift Sacramento, California <br />UNIFORM HAZARDOUS <br />1 erator's US EPA ID No. Manifest Document N <br />2. Page 1 <br />Information in the shaded areas <br />snot required by Federal law. <br />WASTE MANIFEST <br />Y4 1t o . i _ r0 <br />of <br />t <br />rrt6tr'' Nand Mailing Address <br />3.G� <br />t <br />AState Manifest Document Numb <br />� - �#1- 'f <br />' r <br />= <br />. <br />OY�:i3�( <br />d <br />B. State Generators ID - <br />�" <br />enerator'r Phone (. ) `fRysY' p <br />N <br />5. Transporter l Company Name, 6. US EPA ID Number <br />C. 'state Transporter's ID [Reserved;]; <br />LO <br />6 <br />GREEN ENVIRONMENTAL SERVICES <br />D. Tiansporter's Phone <br />0 <br />IC A ID 19 18 12 14 11 13 12 16 12 <br />(800) 972-5284 <br />` <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State1ransporter's ID [Reserved) <br />a, <br />F. Transporters Phone <br />V <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G., Slate.FdcIlity's ID <br />a <br />EVERGMEENIL, INC. <br />Smith Avenue <br />H-futility's Phone <br />O6880 <br />vask GA`945 <br />51 795-4400 <br />U <br />� <br />11. US DOT Description (including Proper Shipping Name Hazard Class, and ID'Number) ' <br />-12. -Containers, <br />_ 13. -Total <br />Quantity <br />IA. Unit <br />Wt/Vol <br />L Waste Number <br />No. <br />.:Type.. _ <br />Z <br />a. ff <br />State <br />3 <br />G <br />WNmR t A HAZARDOUS WAS TIE, UQUI <br />EPA/other <br />1 <br />s T <br />(1 <br />onp <br />C14 <br />E <br />,N <br />_ <br />_;6. - . ----- <br />State <br />°D <br />oo. <br />E <br />R <br />EPA/Other <br />TC. <br />State <br />aC)0 <br />Q <br />EPA/Other <br />r <br />� <br />W <br />d. <br />State <br />Z <br />EPA/Other <br />U <br />LU <br />J. Additional Descriptions for Materials Listed Above1C, <br />Nandlin�;,Codes for Wastes <br />L steel Above ' <br />a. <br />b. <br />m <br />LU <br />Q <br />Z <br />15. Special Handling Instructions and Additional Information J <br />< <br />24 Hour Emergency Response Telephone No., CHI'MTR C : -600-424.9300 Invc�lce <br />Z <br />Pit ` PERPERG 171 WEAR PROTECTIVE EQUIPMENT Sales Order I r. <br />W <br />Umarked, <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, packed, <br />and labeled, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br />If I am a large quantiy 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 economically <br />I have selected method treatment, disposal to the future threat to human health <br />V)d <br />the practicable of storage, or currently available me which minimizes present and <br />practicable and that <br />and the environment; OR, if I am a small quantity generator, ihave made a good faith effort to minimize my waste generation and select the best waste management method that is <br />ae <br />0 <br />available to me and that I can afford. <br />}. <br />Printed/Typed Name <br />Signature. <br />Month Day Year <br />LU <br />(D <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials r <br />Ce <br />R <br />N <br />Printed Typed NaT9 <br />Si§ <br />Month Day Year, <br />LU <br />S <br />LL_ <br />0 <br />18. Trans orfer 2 Acknowle'd ement of Receipt of Materials <br />Q <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />LU <br />N <br />E <br />R <br />Q <br />O. <br />19. Discrepancy Indication Space <br />Z <br />— <br />F <br />A <br />C <br />L <br />1 <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. _ <br />T <br />Printed/Typed NameSignature <br />Month Day Year j <br />Y <br />2 S111a, <br />DO NOT WRITE BELOW THIS LINE. <br />n <br />JAN 2 8 2004 <br />JAN <br />Blue: GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />DTSC 8022A (1/99) <br />To: P.O. Box 400, Sacramento, CA 95812-0400 <br />EPA 8700-22 ENVIRONMENT HEAJH <br />PERMIT/SERVICES <br />