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I � e 0— EES-4 0 <br /> Please print ortype.(Fern designed for use w elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORMHAZARDOUS 1.Oeramtw lD Numbe 2.Page f of 13.Emergency Response Phone 14.Mention Tracking Number <br /> WASTE MANIFEST �+� 9�ZN�� 1 1-800-424-9300 1007039988 JJ K <br /> 5.Generators Name ad Maiug Adki Generators Site Address(8 different than mailing address) <br /> lCOCI-, coL" FP.FmspMf+t1 <br /> K�` I ,L <br /> Genamlors Ph no <br /> B.Tran 1Conwany Name U.S.EPAIDNumber <br /> vergrean Environmental ServiceS CAD982413262 <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Faa14y Name and Sie Address U.S.EPAID Number <br /> EVERGREEN OIL, INC. <br /> 6880 SMITH AVE., NEWARK CA. 94560 <br /> Fackys Phone: 510-795-4400 CA0980887418 <br /> go. lib.LLS.DOT Description(ndu6ng ProperSldpping Name,Hazard Class,ID Number, 10.Contan.8 <br /> 11.Total 12.Unit <br /> HM eM Pakirq Gmup Ofaq)) No. Type OuanBty Wt/vol 13.Waste Codes <br /> 1. <br /> o NON-RCRA HAZARDOUS WASTE, LIQUID 001 TTG <br /> 2.24 <br /> D I L t c,�ci�J ID <br /> z z <br /> w <br /> 3. <br /> C <br /> 14.Sped Harding Inmmctiors and Additional bdonnarim <br /> PROFILE * Invoice # 621Y26Z <br /> DOT ERG#171 WEAR PROTECTIVE CLOTHING Sales Order 4� Lo(: ( TSO <br /> 15. GENERATWSIOFFEROR'S CERTIFICATION:I hereby dedae thatthe comenls of me mssigrmenl we fully and accumtetydescdhed gave by the proper shipping name,and are classified,packaged. <br /> marked ala IabeY.M/pdaraMed,and are In all respects In proper condition fw barspod aaa&g to applicable international and national governonemal <br /> regulations.Negwdshganentmd I as the Primay <br /> Epode,I ceNfy that IM oxdanls of Dols consignment conform W the kms Of the attached FPAALknovdedgmeN of Consent. <br /> 1 unity that the vmwe mirw iration statemerd Identified in 40 CFR 28227(a)if I am a large quanliy generalwt be(b)fit am a smalluant' <br /> 9 M9eneamr)awa. <br /> GenwabrsUmors Preddlryped Name Slgnahre Month Day year <br /> S rJ W S <br /> International Shipments <br /> k— ❑IngodWU.s. ❑EzpoAbom U.S. Pod ofenbylexi: <br /> Transporter nature 1we <br /> W sig ( W^ds only Done awing U.S.: <br /> w 17.Transporter Rao*orMaleria<s <br /> Transporlr l PriptediTyped Name Signature M1tonN Day Veer <br /> 106 1 NO lit <br /> G Tmrepwar 2 PnnWNyped Name S:gnabre Month Day Year <br /> j18.Discrepancy <br /> 18 a.0'sompanglrtucatlon Space ❑ gpynliy ❑Type ❑Residue ❑Periled R beson ❑FuARejecgan <br /> Mani est Reference Number..— <br /> Z <br /> 18b.Alternate Fadldy(w General.) U.S.EPA ID Number <br /> J <br /> U <br /> FedY4(s Ph.. <br /> w ft Sipnalum of Allemate FadWw Generator) Month Day year <br /> Q <br /> 2 <br /> y19.Hazardous Waste Rapod Management Method Codes(i e.,modes for hazardoeswaste treatment,disposal,end mcyding systems) <br /> 2. 3. 4. <br /> 20.Designated Facility Owner w Operator.Cei7metion of receipt of hazardous materials covered by the maniastescept as noted In hem i <br /> PnnteWyped Name Signature Month Day Yom <br /> EPA Form 8700-22(Rev. Previous editions are obsolete. bE51WATED FACIL5X 'STINA N STATE(IF REQUTA."_ ) <br />