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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 G calor I Number .� 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST � �J�v/ fl / 1 1-8U0-424-9300 003336165 JJ K 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generators r'non��D 6.7ranspoV&N�Ap�vnVlronmentai Services CAD982413262 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Addres vergreen i nnc. U.S.EPA ID Number 6880 Smith Ave. Newark,CA 94560 CAD980887418 Facility's Phone: 510-795-4400 FHM. : 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes ji W 9. 3. 4. 14 Special Handling Instructions and RoI I iation I 15. GENERATOR'SIOFFEROR'5 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, marked and labeledlplacarded,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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement Identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a smell quantity generator)is true. Generalor'slOfferor's Prinledrfyped NameSign ure Month Day Year Ab .16.Internalional Shipments z ❑Import to U.S. ❑Export from U.S. o entrylexlt: Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknow ent of Receipt of Materials Transporter 1 Pri ed Name Signature Month Day ear a 3 rig z¢ franspgAr 2 Printed(fyped Name nature Month Day Year 1B.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑ParUal Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number v Facility's Phone: Lo 18c.Signature of Alternate Facility(or Generator) Month Day Year Q z 19'Hazardous Waste Report Management Method Codes(i.e,,codes for hazardous waste treatment,disposal,and recycling systems) rn w 1 2. 3. 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/typed Name Signature Month Day Year wIGL .TI- a1/9f & 03 JIF JID EPA Form B700.22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED