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to C -GenwowDW a 60WTSC�P-0,B"40% A WRI&vAillm 30 Please print or type.(Form designed for use on elite(12-pitch)typewriter.) _ Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST ..z l.- 5 1 f 424- JJ 5.Generator's Name and Mailing Address Generator's Site Address(f different than mailing address) Ut � V �YOT 10, 20 BECKMAN LODI, CA WMA) Generator's Phone: . = - 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number EVERGREEN OIL, INQ WO SMITH AVE. NEWARK94560 Facility's Phone: 140-79,5-44W ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 1 WAa 407 7 1+ G 4 f 5$54$ a*k 'f' ff , taws.�} ,110( z VR tA6V#NQ f 11. o tit fl Its) J. f uWZ, 2y#< 4 fTt; f 1A 7. f.A"1. 'a d ° $" s 5( W4(` 3k 11 t1YU4tnf1 ,'f�IirM ft) 3. 4. 14.Special Handling Instructions and Additional Information 11, -12202 CRO 1711 133W1 1 r 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,arta are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational and national govemmental regulations.if export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b) 1 amA small quantity generator)is true. Generator's/Offerod -Prip d/Typed Name Signature y,r Mongi- D Year -J 16.intemational Shipments i- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: F= Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 efy ed NV 01(l nature MQ4 RV Year 0- U) ZZ Transporter 2 PrintedlTyped Name Signature Month Day Year tr F- 18.Discrepancy 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ V Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) C 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY