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Sep, 22 10 12: 22p Eng�eered Automation (209) 368-0645 p. 8 <br /> • <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Farm Approved.01,18 No.2060-0039 <br /> UNIFORM HAZARDOUS 1 ta�Number /' 2.Page 1 of 3.EmergencyResponse Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST O© !i'1Q�J��i 1 1-800.4249300 JJK <br /> 5.Generators Name <br /> and Mailing Pr1dR55/O�� Generetols She Atldma(irdArerenl than mal address) <br /> 6.TransU.S.EPA ID Number <br /> "'NW4 ' "trIvironmental Services CAD982413262 <br /> 7.Transpoder 2 Company Name U.S.EPAID Number <br /> 8.Designated FaUNy Name and site A vergreen Oil,Inc. U.S.EPA ID Number <br /> 6880 Smith Ave. <br /> Newark,CA 94560 CAD98OBB7418 <br /> Faolll Is Phone: 510-795-4400 <br /> ga 9b.U.S,DOT Description(Incaoing Proper Shipping Name,Hazard Class.IDNuMxm. 10.Conleirars 1t.TOW 12.Unit 13 Waste Codes <br /> MM and Pacxng�W+(Rany) No. Type OuanBty WWN. <br /> / oic77Jcd <br /> = 2. <br /> W <br /> f.7 <br /> 3. <br /> 4. <br /> 14.SRecladH I'6mldgne and Additional Information 4 17� <br /> 15. GENERATORSSIIOFFEROR'SCERTIRCATN)N: I hereby declare that Bre contents of dais mnsigmrsnt are fully and accuratery,described above by the proper skipping name,and are classified,packaged, <br /> makatl and fabeledlplamrded,and mein as respects in pmpermntllbn fortraapon according at appl eade Immatbnal and national gmemnemal regulations,If export shipmenlan d I am the Primary <br /> Exporter,I certify that the contents of this consignment contain to the tame of the allached EPAAduwwledgmeM of Consent. <br /> Icemfy that the waste minieizalion statement identified in 40 CFR 262.27(a)(if l am a large quantity generator)or MI l am a smaa minty generator)is true. <br /> GeneraWelQffem's Pd�lrypad Name /�� SlgnaN d Monty �� %�r <br /> 16.Intemaboral SNpmenls / <br /> f ❑Importb U.S. ❑Export from U.S. P40 entry/exil: <br /> z Transporter signalac(for exports only): Dateleavng U.S.: <br /> W 17.TrenspaterAClpgMedgtrwm of Receipt of Materials <br /> Tmnspaterl r Z ypW Nam SiyaWre McM Day Year <br /> QTrans a 2 Pdnuotyped Name Signature Mornm Day Year <br /> rc <br /> r <br /> 18.Discrepancy <br /> tax.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Ful Rejection <br /> Manifest Reference Number. <br /> 18b.Mamma Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> I Facility's Phone, <br /> W 11k.Signature al Altamate Facility[W Generator) Month Day Year <br /> Y <br /> H19.Hazardous Waste Report Management Method Codes p.e.,codes for hazardous wade treemkm,disposal,and recycling systa s) <br /> 1. 2. <br /> 1 20.Designated Facility Omer or Operator.Certification of receipt of haurdeae materials covered"a maeTest except as need in Item 1 B <br /> P k tadrrypad Name - Signature Mona Day Year <br /> .PA Form 8700-22(Rev.1.05) PreviousediGonsareobsoleta. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />