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1 please print or type. {Form designed for use on elte (12-plh@} typewritW Form A roved. OM8 No, 205ND3' <br />UNIFORM HAZARDOUS 1. Generator ID Number L Page i of I Emergency Response Phone b, Manifest Tracking Number <br />WASTE MANIFEST �llpCJl -�' .�— . 1 -e©0 -424x9$®0 1006661367 JJ <br />i. Generate a flame and Maifirrg lbldraes y.- P}rfj, emitor)5i1s Address (if dlitarenl than mailing address) <br />Generator's Phone: i' l✓T <br />8 Transpadar 1 Company Nmns U,S. EPAID Number <br />Evergreen Environmental Services r CA0982418252 <br />7. Tmnspor1er2 Company Name U.S. EPA ID Number <br />S. Designated Facility Name and Ste Addtesa U.S, EPA ID Number <br />Evergreen 011, Inc. <br />6880 Smith Ave. <br />Newark, Ca. 94560 CAD980887418 <br />Fay's Phare: 510-795-4400 <br />Se. gb. U.S. DOT Description (Including Proper Shipping Name, Hazard Class, W Number, f o, Conialaam 11.711181 tz Unit 18, Waste Codes <br />HM. and Packing Gmup0fm1h) No, Type Ousngty WINol, <br />2. <br />/���'f/)�/� <br />A. W[FJ��� <br />i.l I L <br />SpeeldHjan ungleskmctionsendAddManMln[oanatb j l�ii� ' I .t> fi •5/ G �' t5�' <br />15: • D1;NERATaR'8i0 Ft3t0R'S CERTiFIGATION: t hereby dedara tivtil 4[e contents at tlds cnrrsignment are hilly sod accurately described above by the proper shipping name. and era classified, packaged, <br />marked onafand national governmental regulations. It apart shtpnent end I am the Primary <br />Expedrar, Consent. <br />1 eefury that the wads mkilmlxation sfalementldengfusd in 40 CFR 2S2 27(11) {If i am a Imrge quanuly genemlor} ar @} (If t am a small quantity genas is true. <br />Generel68e aP' ped ma /�f R�/4` Signmlu�,i i/ ' .1 �� Manih �ay _ <br />.r 11 kdoma Shipments <br />Expert from U.S, P enkylexii: <br />Tmnspoderstgnaltrrm erezpadsardy}; IravImgU.5� . <br />17. TratrsltmietAduicnledgmentnfReceiptofMatedels __ _ _. <br />Is.01scrapancy -1 <br />188. Disr�ancy Indication Space Q 0antuy ®Type Q Residue ❑ Padial Ralesifan ❑ Full Rejecuao <br />ManifestRelarence Number. <br />7eb.AhemalsFBeNty(orGenemWr) U.S. EPA ID Number <br />C? <br />Faclidtfs Phone: <br />Tg.Hazardous Waste Report Managementdes(Le., co <br />hLftd Codes for hamnious waste <br />� 1. 141 Vl Z H 1q <br />r+` 24.OesignatedP filyOwrmrarOpeml�Gerlirxafianafreceipldhazanleusmatedalsc <br />FRod/Typed Name ff <br />r an Pmn R7(14-72IRev 3-451 Previous editions are obsolete. <br />,di east, and rainng(systems) ) W <br />If/ <br />the manifest except as nded in item 1611 oe <br />Slgnaiu a t nth Day Year <br />11�.�/� ��i- 1/ 2- 1Z1111_ <br />DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />