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Department of Health Services <br /> State of,California--Health and Welfare Agency Toxic Substances Control Division <br /> {corm Approved OMB No.2050-0039(Expires 9-30-1 „ or e Sacramento.California <br /> Please print or type. fForm designed for use an ell -pitch typewriter). <br /> UNIFORM HAZARDOUS 1, Generator's US EPA ID No. Manifest 2. Page I Information in the shaded areas <br /> ocon <br /> content No. <br /> WASTE MANIFEST p of Is <br /> required by Federal law. <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> y}Af,for}QufA) X14," CO 8 <br /> S-/S�yS�AEC� /hy '57qs 376 8. Siete Generator's ID <br /> 4. GenefaTol"d I;Kne( I 6 3. 6 33"7 <br /> .R <br /> 5. Transporter 1 Company Name C. .I. 6. US EPA ID Number C. State Transporter's ID Q <br /> dba EVERGREEN ENVIRON. SERVICES Cl016191517161 1 D. Trensporter's Phone 800 972-5284 <br /> m 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporier'a ID <br /> F. Transporter's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number -67$tate Facility's ID 7 1 <br /> EVERGREEN OIL INC. <br /> Na 6880 Smith Avenue H. Facility's Phone <br /> o< Newark, CA 94560 7 118 <br /> (415) 795.4400 <br /> OQ 12. Containers 13. Total 14. I. <br /> O 11. US DOT Description(Including Proper Shipping Name,Hazard Class.and ID Number) Ouentity Unit Waste No. <br /> �0 No. Type Wt" <br /> LOU a. HAZARDOUS LIQUID WASTE, ORM-E, UN 9189 state 241, <br /> (.Z. G _- EPA/Other <br /> 00 E 01011 T T 4:1111010 011 G <br /> oi N f State <br /> E b. <br /> oi 2 R q' <br /> A !i/dO'e EPA/Other <br /> OP T <br /> lt D 9 '$t—ate <br /> s R ENVOI pNMENTAL HEALT EPA/Other <br /> W d $tate <br /> Z <br /> Z <br /> W <br /> EPA/Other <br /> U <br /> N J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> Z a. b. <br /> °a 1.1 - Waste Water <br /> 1.2 - 'Waste Oil <br /> J. <br /> J <br /> Q_ <br /> ECE <br /> 15. Special Handling Instructions and Additional information <br /> Z Wear Protective Clothing #5 - CALIFORNIA O!L RECYCL.ERS INC. (C.O.R.I.) <br /> J <br /> J <br /> L) 6. <br /> U <br /> GENERATOR'S CERTIFICATION: I herebyea that[ contents of this consignment are fully and accurately described above proper shipping name <br /> � and are classified,pecked,marked,and labelled,d,and <br /> in d are in all respects in proper condition for transport by highway according to applicable <br /> icable international and <br /> Wnational government regulations. <br /> If I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree 1 have determined <br /> U to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the <br /> present and future threat to human health and the environment;OR,if I am a small quantity generator,I have made a good faith effort to minimize my waste <br /> U generation antl select the beat waste management method that is available to me antl that I can afford. <br /> W Printed/Typed Nam Signature Month Day Year <br /> W v, <br /> 10, <br /> T 77. Transporter 1 Acknowledgement of Receipt of eteriels , <br /> A Printed/Typed me Sig ur Month Day Year <br /> IL S N D /01 / 3 <br /> P <br /> w O 18. Transporter 2 Acknowledgement of Race ipt 1 Materiels <br /> TPrinted/Typed Name Signature Month Day Year <br /> E <br /> Z_ <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Signature Month Day Year <br /> Y Printed/Typed Name 9 <br /> DHS 8022 A(1/88) Do Not Write Below This Line <br /> EPA 8700-22 Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> (Rev.9-88)Previous editions are obsolete. <br /> To: P.O. Box 400, Sacramento, CA 95812-0400 <br /> — Wr <br />