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• <br />• 00204.1054 <br />Form Aooroved. OMB No. 2050-0039 <br />Please <br />printor type. (Form designed far use on elite (12.pitcn) typewnrer.) b <br />ID Number 2. Page 1 of 3. Emergenq Response Phone 4. ManHast Tracking Number <br />UNIFORM <br />HAZARDOUS 1. erotor <br />' '�� 0025.83953 JJK <br />WASTE MANIFEST 000,303W /� <br />Generatols Slle Address (if�ent an ling addJreO <br />5. <br />Generemfs arre and Maiini ress y{ FYI J <br />p-� ! <br />3(��11!S ^i/�L RD .Y�ff114,i 40"1 <br />T7 639�►9�/.a�r. o <br />fs hone: U.S. EPA D Number• <br />Geri P <br />6. <br />Transporter Company Name CAD982413262 <br />Esiergreen Environmental Services <br />U.S. EPA ID Number <br />7. TmnspoMr Company Name <br />U.S. EPA 10 Number <br />8. Designated <br />adlity Name and Site Address Evergreen Oil, Inc. <br />50-7954400 <br />SM Smith Ave. CAD980887418 <br />Newark, Ca. 94560 <br />Facility's <br />Phone: <br />9h. S. DOT Descdptign (including Propel Shipping Name. Hazard Class, l0 Number, <br />,0. Containers <br />11. Total <br />Ouantiry <br />12. Ung <br />Wt.Nol. <br />18. Waste Codes <br />9a <br />HM <br />and Pacltlng Group ('I any) <br />No. <br />Type <br />57 <br />2. <br />W <br />3. <br />4. <br />14.Spedal <br />andlinglnsWdonsandAdditiwal informative <br />7 <br />ear Protective Equipment ERGO <br />voioe/ Sales Order# <br />15. GEN <br />TOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contains of this consignmentam fully and small desmbed above by the proper shipping name, and are dassiried, packaged, <br />national regulations. If export shipment and I am the Primary <br />Markel <br />Exporter, <br />and Iabeledloacended, and are In all respects, in proper amriitlon for transport according to applicable inlamationalalld gmemmental <br />I centty that the,m" of this wn%nment ,Mor, to the terms of the attached EPAA6nowtedgment of Consent <br />I of <br />that the waste mnimization statement identified in 40 CFR 261 if I em a large quantity generator) or (b) (61 am a small quantity generator) is he. Month Day Year <br />Genereofsr08erafa <br />PdntWgyped Name % Signature .. <br />r / 0t <br />16. Internet Shipments ❑ Import to U.S. ❑ Export lean US, of of entrylexe: <br />= <br />Trensportersyni(for exports only): Data leaving U.S.: <br />w <br />17. TransporlerAdToMedgment of Receipt of Materials Month Day Year <br />Trensporter 1 P ype0 Name Signature <br />O <br />O <br />re Month Day Year <br />GoTin <br />rler2 PrinfifiliTyped Name <br />t18. <br />Disaepmcy <br />18a. Discrepancy <br />Indication Space ❑ ❑ Type ❑ Residue ❑ NrU.1 Rejection ❑ Full Rejectlon <br />Quantity <br />Manifest RefarerKe Number <br />18b. -AhBmamt <br />Facility (or Generator) U.S. EPA ID Number <br />J <br />lora. <br />U <br />FacilitysPlioni <br />Monm Day Year <br />w 10c. siiInTre <br />of Alternate Facility(or Generston <br />Q <br />2 <br />y19. Hasa us Waste Report Management Method Codes (i.e., codes for hazardous waste treatment disposal, and recycling systems) <br />C 1 2. 8, 4. <br />�oln I <br />20. Designated Facility owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Monty Oay Year <br />1 Pmted/ryped Name Signature <br />EPA Fan 870G-22 (Rev. 3-05) Previous edmolz 0 <br />10106.0058 <br />are oMiele DESIGNATE�FAGILIIuwrlrvNrrvry ar.uo pr nCx.Vrr,GVJ <br />