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Please print r type.(Form designed forum on aide(12-pitch)typewriter.) �' y j-.�. Form Approved.OMB No.2050-0039 <br /> UNIFOR DOUS 1.Generator ID Number 2 Pager i of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE (FEST 1 09 p5f L /k/;- �5... 1:-800.424-§s3002581 03 JJ K <br /> 5.Genemtafs Name and Mailinpildreis Generators Site Address(if dillerent than mailing address) - <br /> 6-c4.Ck e f- .a <br /> dGyr �. CA era flee L/--,P- <br /> (06, <br /> -(06, (4. S r, y/, <br /> Generatory s Phone: -6 rva <br /> 6.Transporter i 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 /> W80 SMITH AVI NUE <br /> W11ARK CA 946M <br /> Faalitys Phone: 510-796-4400 <br /> (wiF.I�JDx(J.' 7r11+� <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes <br /> HM and Padding Group(t any)) No. Type Quantity W1Nol. <br /> 1. 0i C d 4b 4Y' <br /> o NON-RCRA HAZARD? U5 WASTE,LIQUID TT G <br /> 1' <br /> z Z. <br /> W <br /> 3. <br /> 4, <br /> 14.Spedal Handling Instructions and Additional Information <br /> PROFILE# <br /> DPWbiCH# J�.Z 14 <br /> DOT ERQ# 171 VVEAR PRDTECTIVW CWTHINIG SALES3ORDER* <br /> 15. GENERA70R'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this constptunent are fully and accumley described above by the proper shipping name,and aro classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment ax11 am the Primary <br /> Exporter,I certify that the contents of this conspnment conform to ft tams of the amadred EPAAdmowledgmem of Conserv <br /> Icon ly that the waste minlmlzaeon s nt Identifind in 40 CFR 262.27(a)(R I am a large quantity generator)or(b)if I am a small quantity generator)Is true. <br /> Geruu�s Printedrfyped Nana Signature / Month Day Year <br /> J 16.International Shipments <br /> F- ❑Import a U.S. ❑Exportfrom U.S. P4,d entrylexit <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TranspaterAduawledgment of Receipt of Materials <br /> Transporter 1 Printedrryped Name Slgneture <br /> Monts Day Year <br /> 2 Transporter 2 Printecirryped Name Signature Month Day Yea <br /> <� <br /> H <br /> t18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ (humbly ❑Type ❑Raw. ❑oodle!Rejection ❑Full R.I.O. <br /> Manifest Reference Number: <br /> 16b.Alternate Facility for Generalor) - -- -- _ _ -- U.S.EPA 10 Number <br /> J <br /> LL Facility's Phone: <br /> W 18c.Signature ofAbemale Facility(or Cenemtor) Month Day Year <br /> Q <br /> 2 <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 4. 11 2, 3. 4. <br /> I20. <br /> Designated FacultyOwner or Opemtor.Certification of receipt of hazardous materials covered by mted <br /> e manifest except as no ' Item 18a <br /> PmdedrTyped Name S'- Month Day Year <br /> j UA'K-i, coy Alf r, 1 1/r 7 <br /> EPA Form 8700-22(Rev.3-05) Previous.editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />