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`5 <br /> hpe.( g writer. Form Approved.OMB No.20 <br /> Please print or Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS i. erator ID Number f7' 2.Page 1 of 3 Emergency Response Phone d.Ma Kest Tracking Number JJ I <br /> WASTE MANIFEST L` 1 1-800-424-9300 003336271 <br /> S.Generatofs Name and Mailing Adore M Generators Site Address(if different than mailing address) <br /> 99 <br /> A <br /> ! C�� Z' - w' AsPe . <br /> U.S.EPA ID Number <br /> 6Transeor6rmflnB8ntnvironmental <br /> Services CAD982413262 <br /> o <br /> U.S.EPA ID Number <br /> J7.Transporter 2 Company Name <br /> m <br /> 8.Designated Facility Name and Site Address vergreen Oil, In C. <br /> U.S.EPA ID Number <br /> 6880 Smith Ave. <br /> Newark,CA 94560 CAD980887418 <br /> Facilitys Phone: 510-795-4400 <br /> 9b.U S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Cotler <br /> vHM and Packing Group(8 any)) No. Type Quantity Wt.N}7rrol. <br /> t o <br /> n CD _— <br /> E <br /> 3. <br /> 4 <br /> I <br /> 14.Special Handling Instructions and Additional Information <br /> 3 <br /> `m <br /> i15. 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,pack <br /> - marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulators.If export shipment and I am the Pnm; <br /> 3 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgmen Consent. <br /> 1 cer8fy that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity gen i lam a smal u ntity generator)is true. <br /> L <br /> Gainer oesn00emes Pdntedlry ameSgnat Month Day <br /> l� 17 1Z <br /> I F 16.International Shipments ❑Impel to U.S. - <br /> .S. Port of entry/exit: <br /> Dc Z Transporter slgnature(for expels only). - Date leaving U.S. <br /> w C 17.Transporter Acknowledgment of Receipt of Materials <br /> >: O Transporter 1 Printed[T ame �. Signature l _ Monty Day <br /> Z <br /> Transporter 2 'ntedfryped Name Signatufis Month !/Daly <br /> Q <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fall Re <br /> _ Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> I U <br /> LL Faciltty's Phone: Month Ce <br /> w 18c.Signature of Alternate Facility—(.,Generator) <br /> 6 <br /> z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> D 1' 2, 3. 4. <br /> m 20.Designated Facility Ower or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PdntedffyW Name Signature Month Da <br /> EPA Foran 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REI <br />