Laserfiche WebLink
Please print or type.(Form designed for use on elite'11-pitch)typewriter.) Fortn Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manliest Track(i�ng Number ( �/ <br /> WASTE MANIFEST vV2 61 94 1 ��2Q0�� � JJK <br /> 5.Generators Name and Mailing Address Generators Sitemamsklt different than mailing address) <br /> 2339 'W, :ANrMER LANE, S'iL.C, #300, STOCK'TON, CA 540 N. GRANT STREET, $TOCKTON, CA 95202 <br /> Generators Phone: 2.09-464-0614 95209 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> RAMO'S -MVIRONMENTAL SERVICES F <br /> 7.Transporter 2 Company Name CA d <br /> U.S.EPA ID Number <br /> 6.Designated Facility Name and Site Address U.S.EPA <br /> EVERGREEN OIL, INC, <br /> 6880 SMITH AVENUE, NEWARK, CA 94560 <br /> Faciff(a Phone: (510) 795-4410 ' <br /> 9a. 9b.U.S.DOT Description(irycludirrq Proper Shipping Name,Hazard Class,ID Number, 10.Conlelners it Total 12.Ung <br /> HM and Packing Gmup('d any) 10. Type Quantity WINnit 13.Waste Codes <br /> —RCR.A 11 ARDAJS WASTE LIQUID <br /> (OILY WATER, SLUDGE) J /-T <br /> W ( � <br /> 2 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling instructions andddidonallnformstion ERG04#171 <br /> 9bi) <br /> AVDLERS TO BE TRAINED AND USE 'PPE. <br /> �4 � .� <br /> 15. GENERATOR'SIOFFEROR's CERTIFIC ON: I reb m that contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,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 Primary <br /> Exporter,I ceNy that the contents of this consignment conform to the terms atthe attached EPAAcknowledgmerd of Consent <br /> I rartily that the waste minimization statement identified In 40 CFR 262.27(x)(If I am a large quantity generator)or(b)(til am a small quantity generator)is We. <br /> erreretors/Oterors Pdntedrfyped Name Signature _ Month Day Year <br /> J International Shipments r <br /> Import to U.S. ❑Export rp,�.S. . Port of entry/exit: ^� / r <br /> Z. Transporter signature(for exports only): Date leaving U.S.: z a1 <br /> 17.TransporarAcknowledgment of Receipt of Materials <br /> OTransporter 1 typed Name ; Signature MorM Day Year <br /> 00a <br /> 7�y- Transports 2 d typed Name -� z/ <br /> a Signature Month Day Year <br /> r <br /> } 16.Discrepancy <br /> his.Discrepancy Indication Space <br /> Quantity ❑Type ❑Resitlee ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 166.Alternate Facility(or Generator) US.EPA ID Number <br /> J <br /> V <br /> LL Facitty's Phone: <br /> W 18c.Signature ofAhemam Facility(or Generator) Month Day Year <br /> a <br /> z <br /> S2 19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C3 1' 2. 3. 4. <br /> 1 Lj <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by tt manife'st e t as noted In Item 18a <br /> Pdntecirrylsanill Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />