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ease Plprint or type.(Form designed for use on elite(12-pitch)typewriter. <br /> Form Approved.OMB No.2050-0039 <br /> } UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.MM'+ambast Tracking Number <br /> iWASTE MANIFEST A` 00 o y 0 Ej J b b ( JJ K <br /> 5.Generators Nie and`tiling Adon (kM� 0§ 7a "S' - ss( n mailing address) <br /> `5Mcp W .NC,4 alp�cm Rca� <br /> �yucyt' 13 iib <br /> Generator's Phone: _ 1. .. i <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> FREMOl1YY EWRONMENTAL SERVICES INC. Phom•800.5545274 CAR000171017 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> EVERGREEN OIL. tai c',.SMITH AVE t^ADg8OW7418 <br /> NEWARK,CA 94500 <br /> FaciIii es Phone:510-785.4400 <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Clem,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity VAN& 13.Waste Codes <br /> 1. NggJ4mapdaw Wsale L`,, "(WAKwi`kii 001 TT <br /> 1Q- NOM R(,O.Y1 0AL-0JAW Pi* liq--I <br /> W j 44 v 6W I <br /> z 2. <br /> w <br /> LD <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> HANDLERS TO 0E 441) <br /> PROFILE# <br /> 15. GENERATOWSIOFFEROR'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,packaged, <br /> marked and Iabeledlplacanded,and are in all respects in pr r condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify Nment format the contents of this consignto the terms of the attached EPA Acknowledgment of Consent. <br /> I cebfy that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b) RI spell quantity generator)is true. <br /> Generatorst0lferors PrintedfTyped Name Signature -_ _ Mon Day Year <br /> 16.International Shipments <br /> F <br /> El import to U.S. ❑Fxputfiom lH . Part of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Named� Signature Month Day Year <br /> N VvM Ncl ►i� Nt♦ �� 0 0 0 <br /> 4 Trsnspoder2 ImMedllyped Name Signature Month Day Year <br /> K <br /> r <br /> I <br /> 18.Discrepancy <br /> Isco.Discrepancy Indication Space ❑ Quantity 11T pe <br /> y ❑Residue Fermi Qe' � � t : ❑Fill Rejection <br /> I <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facility's Phone: <br /> Maj[19 <br /> Signature of Alternate Facility(or Generator) Month Day Year <br /> zz <br /> y ..rdtme WasteReport Management Method Codes(i.e.,codes for hazardouswaste treatment.disposal,and recyding systems) <br /> + 2. 3. 4. <br /> F`P:� <br /> Owner orOperator.Certification of receiptof hazardous materials covered by the manifest exceptas noted in Item 18a <br /> yL4ed Name Signature Month Day Year <br /> c� <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />