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Please print or type. (Form designed for use on elite (12 -Ditch) typewriter.) <br />D T S C- 0:0;8 95 - 1.468 <br />Form Approved. OMB No. 2050-0039 <br />trA corm 87UU-22 (Kev. 3-05) Previous editions are obsolete. ,keN(rATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />10499.0415 <br />UNIFORM HAZARDOUS <br />1. G rator I Number <br />73 �3 <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manffest Tracking Number <br />002390250 JJ K <br />WASTE MANIFEST <br />1 <br />1-800-424-9300 <br />5. Generator's Name and Mailing Add ss/ �CJ�'% �/ ZoLfGenerators Site Address (it different than mailing address) <br />Generators PhanelJ� �/ritor,/,a�G¢ , p3z7 i <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Evergreen Environmental Services CAD982413262 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />Evergreen Oil, Inc. <br />6880 Smith Ave. <br />Newark, CA 94560 <br />Facilitys Phone: 510-795-4400 CAD980887418 <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Gass, ID Number, <br />and Packing Group (if any)) <br />10. Containers <br />11. Total <br />12. Unit <br />13 Waste Codes <br />No. <br />Type <br />HM <br />Quantity <br />Wt.Nol. <br />W <br />2-0 <br />41 <br />UJI <br />2. o� 7G�/fer✓,j, <br />L <br />300 <br />I <br />3 <br />4. <br />14. Special Handlin Instructions and didonal Information <br />Z. - &46 p3/--1.7, <br />7 <br />15. GENERATOR'SIOFFEROR'S 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, <br />marked and labelediplacarded, 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 <br />Exporter, I cerlfy that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent - <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if] am a small quantitygenerator) is true. <br />Generators/Offerors Pnnted(ryped me Signature Month Day Year <br />' ga <br />Z <br />16. International Shipments <br />1:1 Import to U.S. ❑Export horn U.S. Port ofentry/exit <br />— <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. TraruponerAcknowledgment of Receipt of Materials <br />O <br />Transporter 1 Printe Name Signature Month Da Yea <br />a <br />Transporter MntedlTyp6crName Syn re Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />U <br />LL <br />Facilitys Phone: <br />w <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />a <br />z <br />S2 <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />UJI C <br />1 L4-1 <br />1� / <br />2 141 <br />20. Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />l <br />Printed/Typed Name Signature Month Day <br />Day Year <br />I Ca' 1 /q 169 <br />trA corm 87UU-22 (Kev. 3-05) Previous editions are obsolete. ,keN(rATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />10499.0415 <br />