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Please print or type. (Form designed for use on elite (12 -pitch) typewr UNIFORM HAZARDOUS 1. Generator ID Number WASTE MANIFEST 5. Generators Name and Mailing Address a -S INC Generator's Phone: t{2g)94&9701 Box 400, Saaamento, 'C4 v t jlh.30,dSIy�r fl r.) Form 2. Page 1 of 3. Emergency Response Phone4. Manifest Tracking Nu i��4300010 Generator's Site Address (if different than mailinc address) OMB No. 2050-0039 JJK 'r./LY%Ar/.�'d�,L7�j`%'7i�Il.Yct�/(%%f.$�.� i�".ily.,/ s/.✓✓��Ji�I' 14. Special Handling Instructions and Additional Information - A. 7�3 E. 1 r?8-$IG4�dt7 R- 11643 C'Rcs 133-0.62 � � '.�. 5_ L%rat iEiFlt�ilfL C. 7-4645 ERG 171-9t3 e7b 138-W2 15. GENERATOR'S/OFFEROR'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, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intematlonal 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 EPA Acknowledgment 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 small quantity generator) is true. Generatorsl0ifertf�s Printed/Typed Name Signaturl�re - 711 y Month Day Year l7tr' b� -J 16. Intemational Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: Z Transporter signature (for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials . Monti Day Year �f Z Transpo er 2 Printed/Typed Nhme Signature Month Dav Year 1 18. Discrepancy 18a. Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection 18b. Alternate Facility (or Generator) Manifest Reference Number: J U.S. EPA ID Number _ V Facility's Phone: W 18c. Signature of Alternate Facility (or Generator) Month Day Year Q Z H1. 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) LLJ H1t/ i 1 2 3 ��l�� 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 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR J �r F---1 aVIY :ONldr?EtYTAL Y ERVIcES -- rn iU rvuinuer CA 824 f., ENWRilhi 7. Transporter 2 Company Name Au - U.S. EPA ID Number HEALTH DEPA 8. Designated Facility Name and Site Address EVERGREEN OIL, INCL U.S. EPA ID Number 6WO F-441'fH AVE, CADSIBM7418 NEWA R, (;A 54560 Facility's Phone: 510-795-44DID ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 2. Unit Unitol. HM and Packing Group (if any)) Quantity Wt./ 13. Waste Codes No. Type P4`"'».�, Vd At/'PAR'l s��.:_LNTtKl IhiAT�fYika-. �, I4 a 2 "1 f31.ilj Qo w ZUNIS25, WAb-TE F-t:rPAVA—SLC: CgOLIDN, CRC V4C, KOI�B., 4J1 , at V401 X �O�FSRG x4, Tag- 3� , C ,'r3223 'r./LY%Ar/.�'d�,L7�j`%'7i�Il.Yct�/(%%f.$�.� i�".ily.,/ s/.✓✓��Ji�I' 14. Special Handling Instructions and Additional Information - A. 7�3 E. 1 r?8-$IG4�dt7 R- 11643 C'Rcs 133-0.62 � � '.�. 5_ L%rat iEiFlt�ilfL C. 7-4645 ERG 171-9t3 e7b 138-W2 15. GENERATOR'S/OFFEROR'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, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intematlonal 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 EPA Acknowledgment 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 small quantity generator) is true. Generatorsl0ifertf�s Printed/Typed Name Signaturl�re - 711 y Month Day Year l7tr' b� -J 16. Intemational Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: Z Transporter signature (for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials . Monti Day Year �f Z Transpo er 2 Printed/Typed Nhme Signature Month Dav Year 1 18. Discrepancy 18a. Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection 18b. Alternate Facility (or Generator) Manifest Reference Number: J U.S. EPA ID Number _ V Facility's Phone: W 18c. Signature of Alternate Facility (or Generator) Month Day Year Q Z H1. 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) LLJ H1t/ i 1 2 3 ��l�� 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 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR J �r