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Please print or hype. Form designed for use on elite(ll-pita.,.yPewriter.) Form Approved.OMB No.1050-0039 <br /> UNIFORM HAZARDOUS 1. tar ID Number 2.Page I of 3.Emergency Response Phone 4.ManteslTracMnHumber <br /> WASTE MAIRFEST11 03 1 _ 1-8W-424-9300 0023'9 0 3 4 6 JJ K <br /> 5.Genera�Ws Name am! <br /> MMagrmgr/L/_/�' Ge mWsSite Addw(AURwenlNanma6ngadNess) <br /> Ga�erefbls Phace�9�J" �z�/3l� /,v4MC1A <br /> 6.Transporter I Company Name cY� 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 /> FaciRi IsPhene: 510-795-4400 CAD980887418 <br /> 9a. W U S.DOT Desorption(mdudkV Proper Shipping Name,Haeard Class,ID Number, 10.Contairrers 11.Total 12.Uril 17.Waste Codes <br /> HM and Paddng Group(e any)) No. Type UrenBty WIN& <br /> 14'::111 <br /> i 2 <br /> W <br /> 7. <br /> 4. <br /> 1/.Special Handling lnsWgaana andAddifional thformation _ V/=e, <br /> 15. GENERATOWSIOFFERDR'S CERTIFICATION:I hereby declare hal the contents of this opusovent are fueyana accurately described above by to proper slepprg name,and are classified.packew. <br /> marked and labeled/placarded,and are M a8 respects in proper=41don ler banaporl acoadng to applicable imemaeonal and naeonal governmental regulation,It espol shipment and I am the Primary <br /> Exporter.Iogthat tire contents cl tlds consignment=.tom to the lean of the attached FPAAcknpM Conan <br /> I rorty the the waste minimization satemant identified m 40 CFR 28227(a)(t I am a lerge gvantiry genet o b)(RI a rely generator)is true. <br /> GeneaW aPr;Typed Signam . Moms Dry Year <br /> d (l1 ('ty/ 3 y 0 <br /> F 16.International shipments ❑4npMfo US. - ❑Epol from U.S. Palatentryl <br /> i Transporter straw(for asporta oNy): Date"U.. <br /> 17.Tmsponer/dmmledgnamof Re*of Materials <br /> R Trenapner 1 ,ped Nem�� sial `A Y <br /> 2 T 2PMtetl/Typetl Name San Month Day Year <br /> I8.Dieoapanry <br /> 1 18a.0coapercy In9ntan Eleam <br /> SpaDYy ❑Type EIResidue ❑Partial Refection ElFull Re ectlan <br /> Manlike Reference Numbv. <br /> I W.Alternate Fadity(or Generation U.S.EPA ID Number <br /> V <br /> LL Facliys Phone: <br /> Mop IBC Signature ufAlremeb Fasly(er Generator) MOM Day Year <br /> 1�y 19.Hasardous WacaRepoRMawgemNd Method Cotler Pa..codes for haeardoue waste aaaanam,disposal.XWmRdrg sYsM=) <br /> O 1. 91"'4-1 z 3. 4. <br /> 2D.DempraM FadNy Owneror Operall Certification draceipt ofha ardor maadah covered by the rravilea escept n nded'm Item 18a <br /> 1yped Nang Month /Day Year <br /> Q1aI `i <br /> EPA Form 8700-22(Rev.3-05) Previoulifeditions are obsolete. 10508.0893 GNATED FACILrTYTO DESTINATION STATE(IF REQUIRED) <br />