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Please print or type. (Form desioned for use on elite (12 -pit r.) <br />Fnrm AnnmvAd ouR mn )n;nmgo <br />CrA Form or00-22 (Rev. s-uo) rrevwus eomops are o0wete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS 1 Generator ID Number <br />WASTE MANIFEST .fS`cS7� <br />2 Page 1 of <br />1 <br />3. Erthergency Response Phone <br />1-800.424-9300 <br />_1 ---- <br />4. Manifest Tracking Number <br />0 06661457 JJ <br />5. Generators Name and Melling Address 04F. Generators Site Address (If different than mailing address) <br />aillo- <br />Generators Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Evergreen Environmental Services CAD982413262 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address Evergreen Oil, Inc. U.S. EPA ID Number <br />.6880 Smith Ave. <br />Newark, Ca. 94560 CAD980887418 <br />Facility's Phone: 510-795-4400 <br />ge. <br />9b. U.S. DOT Description (mduding Proper Shipping Name, Hazard (lass, ID Number, <br />and Packing Group (If any)) <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />HM <br />No. Type <br />Quantity <br />WWd. <br />2rf'/ / % / ✓%�,0�� liql <br />'00w/ <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information e�L _ E <br />®� f,ti! / o <br />y► <br />15. GENERATORS/OFFERORS CERTIFICATION: I hereby declare that the contents of this consignment are 44 and accundaly described above by the proper shipping name, and are classified, packaged, <br />marked and labeled/placarded, and are In ell respects In proper condition for transport according to applicable kntem a national regulations. If export shipment and I am the Primary <br />Exporter, I certty that the contents of this consigmrhent conform to the terms of the attached EPA Acknowledgment of 9&4t <br />I certify that the waste minimization statement identified in 40 CFR 26227(a) (If I am a large quantity generator) or (til sh a snolqualfity, generator) is true. <br />Ge s Printed/T Na Signa Month Day Year <br />3 �7 ll <br />ai JZ <br />16. Intematio nal Shipments <br />❑ Import to U.S. 0 Export from U.S. Port of entry/exit <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />Trans7 Printed/Typed Narrhe S�Month <br />a <br />p� Year <br />H <br />zQ <br />TransMftr 2 Printed/Typed Name Signature Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space El Quantity 0 Type Roue E] Partial Rejection ❑ Full Rejection <br />Mantfest Reference Number. <br />18b. Altemate Facility (or Generator) <br />U.S. EPA ID Number <br />C:t <br />U. <br />FacilitysPhone: <br />18c. Signature of Aftemate Facility (o Generater) <br />Month Day Year <br />N19. <br />Hazardous Waste Report Management Method Codes_ Q.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />G <br />1. <br />2. 3. <br />4. <br />20. Designated facility Owner or Operator: Codification of recelpt of hazardous materials covered by the mantled except as noted In Item 18a <br />PrintedlTyped Name Signature Month Day Year <br />CrA Form or00-22 (Rev. s-uo) rrevwus eomops are o0wete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />