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i• .x*Ganerator,Mail a copy to: DT' P.0.Box 400 Sacramento,Ca.95812-0e-)vthin 30 days.* <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) EES-4 <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page i of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 009434199 JJ K <br /> S.Generator's N me and MoilingAddress 1 rs bur424-93D0 <br /> Ge ratols Sitddress(if deferent than mailing address) <br /> V10 {/rKll/7/ i� i}L SaR�/�«5 ° l(� F� G/LDdSTQt�� irrC_ <br /> laS NeHL �}tLlr R� (1L10 <br /> C.�lGEB-n�i�L� �0 .��o P.9 tg'fa7 TT <br /> G"eneialu�Pfidn -- - -- -- 'f 9- -- -- __ -_. t>T&c K--re CA -.�fr...7La/. <br /> 6.Transporter) ny Nam 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 EVERGREEN OIL, INC. U.S.EPA ID Number <br /> 6880 SMITH AVENUE <br /> NEWARK CA 94560 CAD980887418 <br /> Fadfitys Phone: 510-795-4400 <br /> gra, 9b.U.S.DOTDescripticn(including Proper Shipping Name,Hall Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quanfity WLNoI. 13.Waste Codes <br /> 1. <br /> o NON-RCRA HAZARDOUS WASTE, LIQUID 001 TT G 2Z3 <br /> OiL� �vA-i� 3S i1 <br /> Z 2. <br /> LJ <br /> 3 <br /> 4 <br /> 14.Special Handling halm tions and Additional Information <br /> PROFILE# INVOICE#Q/0C- <br /> DOT ERG# 171 WEAR PROTECTIVE CLOTHING SALES ORDER # <br /> 15. GENERATOR'SIOFFERON SCERnFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and am classified,packaged, <br /> marked and IabeleNpladaided,am min all respects in proper condition for transport according to applicable international and national governmental regulations.if export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknovedgmenl of Consent <br /> I certify that the waste minim¢ation statement identified in 40 CFR 262.27(a)(t I son a large quantity generator)or(b)if I am a small quantity generator)is he. <br /> 33weratDi'dOterors Printedrryped Name Signature Moon Day Year <br /> 4/1 <br /> 1 It S i3 <br /> 16.International Shipments <br /> F ❑Import to U.S. ❑Export tom U.S. Port ofani <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W17.Tmns=rAcloiowledgment of Receipt of Materials <br /> Trans 7m; yped Name Signature Mont Day Year <br /> y . b l <br /> Q <br /> Transporter2 PdntedRyp Name Signature Month Day Year <br /> 19.Discrepancy <br /> Ile 13a.Discrepancy Indication Space ❑ Quani ❑Type ❑Residue ❑P FA Replichom <br /> Manifest Reference Number ' <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID NumberAUGV AG <br /> LL Faalityp Phone. <br /> w, 18c.Signature of temate Facility(or Generator) i Year <br /> 2 l' <br /> jr <br /> nr_p nTh( \I'r.. <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recy irg systems) <br /> 20.Designnaatteed Facility --Owner or Operator Certification of receipt of hazardous materials covered by the mao'test except as noted in Item Its ' <br /> Pante NameSgn�torg��— j Month Day Year <br /> 16111 S- 11-3 <br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> I <br />