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yr <br /> C��S, I Generator's US EPA ID No 2 Page 1 3 Document Number <br /> NON-HAZARD <br /> ` of NH— # 1059 <br /> WASTE MANIFEST' 1 <br /> 4 Generator's Name and Mailing Address 4�,�r EES 19 <br /> 7, <br /> Generators Phone r-27t4, <br /> 5 Transporter Company Name 6 US EPA ID Number 7 Transporter Phone <br /> EVERGREEN ENVIRONMENTAL SERVICES <br /> CAD982413262 800-972-5284 <br /> 8 Designated Facility Name and Site Address 9 US EPA ID Number 10 Facility's Phone <br /> n <br /> Evergreen Oil, Inc <br /> 6880 Smith Avenue <br /> G Newark, CA 94560 CAD980887418 510-795-4401 <br /> E 11 Waste Shipping Name and Descnption 12 Containers 13 14 <br /> N Total Unit <br /> E No T e Quantity WI/Vol <br /> R a <br /> T on-Hazardo�waste, liquid 001 TT G <br /> Q ter and oil <br /> R -7 1 Special Handling Instructions and Additional Information Handling Codes for Wastes Listed Above <br /> 11a 11b <br /> Profile# <br /> Do not ingest <br /> Wear protective clothing Invoice ���-� <br /> In case of emergency call CHEMTREC 800-424-9300 Sales Order <br /> DO)T ERG 171 ^+� r f <br /> Vj'✓i-�'� _4yy J S r /Ji r Lir S7"k-7+u, / <br /> 16 GENERATOR'S CERTIFICATION I car*the materfafs described above on this inandest are riot subject to state ortederal regulations for rapottato proper disposal of Hazardous Waste. <br /> PnntedCryped Name Signator <br /> f � Month Da Year <br /> R <br /> Ii/` � ( �c�(,� Go, 4I�C/" /i L11 21 <br /> ?!a rT <br /> S 17 Transporter Acknowledgement of Recelpt of Materials "r <br /> PO Pnntedfryped Name Signature <br /> R <br /> Tf dd � Month Day Year <br /> 18 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> i <br /> 10 Fadlity Owner or Operator Certification of receipt of writs m6itetials oo4i 9d W this manifest except els noted in Item 18 s y � � t `4-; 'ani„ <br /> Pnntedfryped Name Signature <br /> Month Day Year <br /> WHITE--ORIGINAL(Return to Generator) YELLOW—TSOF(Retain Copy) PINK—TRANSPORTER COPY GOLDENROD—GENERATOR'S COPY <br />