Laserfiche WebLink
Please print or".(Form designed for use on elite(12-pitch)typ.ariter.) 7 Form Approved.OMB No.2050-0039 II <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone f Manifest Tracking Number <br /> UNIFORM HAZARDOUS CAID003'L'o107 1 �4�3 ay� 006396644 JJ K <br /> WASTE MANIFEST <br /> fo[s.Ff aSnd Maigng Address Generators Site address((diBerem than madmg address) <br /> 1099e S. HARLAN RD. <br /> FRENCH CAMP,CA 95231 <br /> Generators Phone: <br /> 2OcI-983.6970 <br /> 6.Transppoonner 1 Companyy Name U S EPA ID Number <br /> EVERGREEN EPRONMENTAL SERVICES CAD%--2A13 62' <br /> W.Transporter 2 Company Name U.S.EPA ID Number <br /> PHILIP WEST INDU81RL41 SER\qCE:'� INC. CAR0001775, <br /> Desk a F mqq and Site Address U S EPA ID Number <br /> 1St' tiv , t=Nilnn.nnonati ox <br /> 2045 NEWLANDS DRIVE EKST <br /> FERNLEY.MJ E94O6 <br /> 775-575-2760 <br /> Facilitys Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11 Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wl Nol. <br /> ?77W (� <br /> w 2 — <br /> � l z13 <br /> u` <br /> O --- <br /> t <br /> 3. I <br /> 4• i I <br /> 14.Special Handling Instructions and Additional Information <br /> prottle / 01-2 -OD erg Crum size <br /> 15 GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fullyand accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labetedlpladarded,and are in all respects in proper condition for transport according to applicable.intemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAckriowledgmen(of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(d 1 am a large quantity generator)or(b)(if I am a small quantity,generator)is true. <br /> GenerctoeslOfferors Printed/Typed Name Sig tura Month Day Year <br /> 116.Intemational Shipments.z ❑Impod to U.S. ❑Export from'U.S' Port of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> Wi 17.Transporter.Ac . edgment of Receipt of Materials <br /> Transporter 1 Paph,4Kyped Name Signature Mont Day- Year <br /> OW <br /> Transp r2 PrintoJiped Name Sig re Mordh Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> ❑ <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> u-- Facility's Phone: <br /> W 18c.Signature of Alternate Fac lily(or Generator) <br /> Month Day Year <br /> a <br /> z <br /> CD <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste veabnent,disposal,and recycling systems) <br /> LU <br /> 1. 2 <br /> 20.Designated Facility Owner or operator Certification of receipt of hazardous materials covered by the manifest except as ncted in Item 18a <br /> ry nnLdlTyped Name Signature Month Day Year }� <br /> v 8700-223-05 Rev. I <br /> ( ) p R <br /> reviousedttionsareobsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF EQ(/f/3ED) <br /> t, + <br />