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Please print or45'as.(Formdesigned for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2050.0039 <br /> UNIFORM HA7ARDOUS 1. naratm ID Nu r������ 7.Pape 1 of 3.Emergency Response Phone A.Manhat Tncknp Number <br /> WASTE MANIFEST - 1 1-800-424-9300 002390184 JJ K <br /> S.Generators Name and Mailing Address /_� ^✓L v- - Generator's She Address(if difierent than mailing address) <br /> 5�-'j015 <br /> Generats Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Evergreen Environmental Services CAD982413262 <br /> 7.Transposer 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility New and Site Address U.S.EPA ID Number <br /> Evergreen Oil, Inc. <br /> 6880 Smith Ave. <br /> Newark,CA 94560 <br /> Facill es Phone: 510-795-4400 CA 9808B7418 <br /> 9e, 9b.U.S.DOT Dasadp8on(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit No. 13.Waste Codas <br /> HM end Packing Group(d any)) Type QuantityWI.Nd. <br /> 1. <br /> = 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handing Instructions andA4clitiorral Information <br /> 15. OENERATORI&DFFEROR'8 CERTIFICATION: I hereby declare that the contents of this conalpnment are fully and accurately download above by the proper shipping name,erd are classified,paokaged, <br /> marked and lebe"iscarded,and are M all expecte In proper candttbn for transport according to applicable marnetlenal and netlon it governmental regulations.R export shipment end I em the Primary <br /> Expo4r,I cardy,that the contends of this consignment cordorm to the tome of the ahacied EPAAcknowkdgment A Convent <br /> I carthy that the waste minimization statement Identified In 40 CFR 262.27(x)(8I am a Wge quently )or(b)(II I am a small quantity generator)is true. <br /> Gansmait'slOAerofe PdN Month Dey Veer <br /> .Intemetbne 9 PneMe ❑Import to us. ❑Fxport from U.S. Pod of entry/aft: <br /> Transporter slpn itue(fix exports ony): Date leaving U.S.: <br /> 17.TmuporterPcknoeleVnent of RKW of MalerWe <br /> Transporter 1 P Nam 5il;ne M 0 De Y <br /> De is, <br /> e r2 d yped Name 51pnatue Month Day .Year <br /> 1 18.Dbcrepancy <br /> 18a.Discrepancy indication Space ❑ Quantity ❑Type ❑Read. ❑FoNet Reye tlon ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Ahemate Fedlfty(or Generator) U.S.EPA ID Number <br /> V <br /> FaclIV6 Phoa: <br /> <� 8c_SlgneWreof9lteavleFaGlky�arGenerabr Month Day Year <br /> Z <br /> 19,Hazardous Waste Report Management Method Codes(i.e.,codes far hazardous waste treatment,disposal,and reryding sylMne) <br /> 1. 2, 3. 4. <br /> 1 20.Deelpneled Faculty Owner or Operator Certhrmtbn of receipt of hazardous materiels covered by the mandest except as noted In Item 18e <br /> PdntedRypetl Neme Sitature Monty Dey Year <br /> .PA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE!IF REOUIRED) <br />