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Please print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No. <br /> 1. e r ID Number 2.Page 1 of 3.Emergency Response Phase 4.Manifest Tracking Number <br /> WASTE HAZARDOUS <br /> /zo3� 1 1-800-424-9300 <br /> 1003336017 J, <br /> 5.Generators Name and Mailing Address 404e 'ebljj Generators Site Address(d different than mailing address) <br /> - <br /> o Ge mfors Ptane: - / �� � `'rye • /��� <br /> s.rranspo 4 den Environmental Services U.S.CAD982413262 <br /> 0 <br /> 0 7.Transporter 2 Company Name U.S.EPA ID Number <br /> m <br /> 8.Designated Facility Name and Site AddresEvergreen Oil, Inc. U.S.EPA ID Number <br /> 6880 Smith Ave. <br /> Newark,CA 94560 CAD980887418 <br /> FadTrtys Phone: 510-795-4400 <br /> So. 91b.U.S.DOT Description(including Pmper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit 13,Waste Code <br /> rn HM and Packing Group if any)) No. Type Quantity WINd. <br /> co TIP011 <br /> PLI <br /> - s <br /> DIM <br /> CD <br /> _ m 3 _ <br /> N <br /> l <br /> � 4. <br /> N <br /> m 14.Special Handling In it Additional information �-,z^ n� ` i33 <br /> �I <br /> 99v-/ 79,35 -171� <br /> vlZ 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of the crosgnn*A are fully and accurately desoibed above by the proper shipping nacre,and are classified,pada <br /> marked and labeledlplararded,and are in all respects in proper om d bon for transport according to applicable intemationalan0 national governmental regulatlons.If exportshipment and am the Prim, <br /> 3 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAUmaNedgmam of Consent. <br /> w 1 certify that the waste mini ni ation statement identified in 40 CFR 26227(a)(d I am a large quantity generator)or(b)(itI am a small quamily generator)is We. <br /> Generators/Offerors Pdntedrfyped Name Signature, Month Day <br /> x ��5� Af f ' 0 1�5 <br /> N , <br /> < 16.International Shipments <br /> m F ❑Import to U.S. ❑Egwdfrom U.S. Port of entrymAt <br /> wTransporter signature(for exports only): Date leaving U.S.: <br /> w C17.Transputer edgmrerml of Receipt of Mathrmis <br /> z K Transporter 1 P' yped Name Signature Month Day <br /> D ?� <br /> M Tans r2 minted ped Name Si re Month Day <br /> j18.Disaepanry <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Reje <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPAID Number <br /> J <br /> U <br /> LL Fadlilys Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day <br /> a <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recydvg systems) <br /> 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a - <br /> 1 nmd1Tvoed Name e:...,..«.... <br />