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Please print or type.(Foran designed for use on elite(12-pitch)tpewf9ter) Fcrn Approved.OMB No.20504039 <br /> UNIFORM HAZARDOUS 1.Generate ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking umber <br /> WASTE MANIFEST 1 1-800 424-9300 JJ K <br /> 5.Generatnrs Name and Meiling Address? <br /> ddress r Generator's Site Ado rtss(it dllfereru than melting address) <br /> -71 <br /> Generators Phone: <br /> S.Transporter 1 Company Name U.S."PA Number <br /> Evergreen Environmental Services 8A 982413262 <br /> 7,Transponer 2 Company Name U.S-EPA 10 Number <br /> 8.De4nated Facility Name and Site Address Evergreen Oil,Inc. US.EPA ID Number <br /> 6880 Smith Ave. <br /> Newark,Ca.94560 CAD980887418 <br /> Facillys Phone: 510-795-4400 <br /> gra 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number. 10.Contansrs 11.Total 12-Unit 13 Waste Codes <br /> HM End Pecking G—P(ifanY)) No. Type OU-11ty WVVoI. <br /> AW <br /> 1 <br /> 2. <br /> LLY <br /> a <br /> t• <br /> 4. <br /> 14.Sper�al Handling hlstrucborts andA Donal InformabWt �� i 7 f ��� / <br /> 15. GENERATOR WFFEROR'S CERTIFICATION:1 hereby declare that the contents of this consignment m fully and accurately described above by the proper shipping name,and are c1miHed.packaged. <br /> marked and labeledlptecarded,and are in all aspects In proper condidon for M%pat acwrdtng to applicable intamalional and national governmental regulations.If export shipment and I am tM P11rnary <br /> Exporter,I candy that the contents of thb conafgnment conform to the terms of[he attached EPAAcimdwledgmemt of Coneenl <br /> I txfdfy that the waste minimization statement iden118ed In 40 CFR 26227(a)(8I am a large quantity generator)or(b)(if I am a small quantity generator)i9 trve. <br /> Generatorsl0ffetoes Print"I yped Name IgnaWre Month Day Year <br /> -j 18.intemaUonal shipments <br /> F Import to U.S. Export from U.S. Port of entrylexIt <br /> K Transporter signature(for exports ordy� Date leaving U.S.: <br /> (y- 17.Transport rAWTAt4mcnt of Recdpl of Materials <br /> Transporter 1 Printed/Typed Name S gnalu Month Day Year <br /> aTransporter PrintedirTyped Narft Signature Month Day Year <br /> r <br /> 18.Discrepancy <br /> 18e.Dwspancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fuca Re)ecUon <br /> Manifest Reference Number. <br /> 18b.Alternate Facblty(or Generator) U.S.EPA 10 Number <br /> V <br /> FadBtys Phone: <br /> Sc.Signature ofAllernale Facility(orGenerator) Man Day Year <br /> d <br /> 2 <br /> ti19.Hazardous Waste Report Management Me"Codas(I.e.,coda for h2ZWOUs waste treatreent deposal,and recycling systems) <br /> UJI of C <br /> ' ` ///`T 2 , ` /�/ 3. <br /> 20.Desigratsd�Flaality Owner or Operator.Cenifintfbn of receipt of hazardous materials cowered by the manifest except as noted In Item 188 <br /> rale ped Namesignatius Month Day Year <br /> Ire I IL <br /> EPA Form 8700-22(Rev.3.05) Previoua ed orts are obsolete. ATED FACILITY TO DESTINATION STATE(1F REQUIRED <br /> cnn .J W,l U :71 (1 m iifl7.-( i-qnv <br />