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08/15/2013 14:20 209529.1 - P.OYE T i WAREHOUSE PAGE 06/13 <br /> Cvmvatu'; ` 8a ' 'ir'iia`?: •9 a=. ,`y.X-�-� 4'V,r°�.°" r "ad n CA 55812 �+V l l rr� iA <br /> Please print or type.(Form designed for t se�n oiife(12-pitch typevrriter.) <br /> Form Approved.OMB No,.2050-0038. <br /> tUNIFORM HAZARDOUS 1.Gena 3gIP hlumhcr _°a o5`1 r:f t J-Emergany R"eSLG!`.SE P:iGne 4.Manifest Trraack[ng NNxumbarr � JJ K <br /> 1 r WASTE MANIFEST _ ;$s� a�� -� i.r 33 <br /> Generator's Name and Mailing Address Generators SitsAddrev(if di1'fereni than mailing edIIECEIVEP <br /> Q3ft 17 W LAI <br /> �0TEC A,CA Q 35 <br /> C?enerator's Phcna: U.S.EPA ID Numb, <br /> A <br /> .TranGporlar 1 Company Name <br /> 7,Transporter 2 Company Name U.S.EPA tD <br /> HEALTii DEPARTMENT <br /> £,.Qe ignatad F=ity Narno and Site Address - U.S.EPA 11)Number <br /> It <br /> EVERGREEN OIL, INIQ. <br /> SW SMITH AVE. <br /> FaClll s Phare: <br /> ga <br /> ob.U:S.DOT Descr ption(including Proper Stripping RM Hazard Class,ID Number, 10.0Or1t31ners 11.Taal 12 Us)i: 13.Wasts Codas <br /> HM and Packing Group(if arty)) No. type Ruantlty �Nc�Vc:. <br /> � I <br /> Hl"C�FtCCA3 d ) 4 Div 0 J <br /> t <br /> do <br /> chr <br /> i <br /> a. k t <br /> t <br /> F 4.Special Handling Instructions and Additional information <br /> ----- Q.� it�ei<irr— <br /> _._ 7 <br /> 51 <br /> 15. GENERATOR'SlOFFEROR'S CERTIFICATIONr thereby derlars thallhe Contents of the consignment a e fdlfy,rd accurately dasu d above by the proper shipping nature,aro aret a classified,packaged <br /> marked and labeledlplacarded.and are in all respects in proper condition for transport according 4}appN able international and RaBunal govemmantal regulations.If exportshipment and I am the Pbmary <br /> Exporter l ceNfy that the contents of this consignment rontwrn to the tarns of the attarhed.cPAAoknmAodgmentof Consent. <br /> cerHiy that the wesfa min n za#oa 9t:+.lament i lrnt ed in 60 CFR 2Fi227(a}(ff I am 5 latae Guanfr y generator)or(b)(f I am a small gUal%,generator)is a. <br /> Signsnrrz Month Ddy Year <br /> GP,.neraior`z10 ferofS Printe'd/Typed <br /> —1 16.Intrmationai Shipments F Fyppr',from U'.S. Porto/iry,'exr:--- - <br /> � 01 Import to U,S. <br /> U.S.: <br /> F: Transperter7'q*um(forexperm only): C:^z Ie3U!ng <br /> W <br /> 17,TransporterAcimowledgnlentofReceiptofMateriai8 Month Ds yesr <br /> Transporter rinted/IypadNama Siena r <br /> . - Month Day Year <br /> 4 Transporter 2 PrintedlTyped Name S;gnatur6 <br /> rY i <br /> 18.Discrepancy <br /> 1sa.Discrepancy indication Space ❑ QuantityC Tyr ❑Reetdua �Psrdsl Ra}action ❑Full Rejection <br /> eacasl <br /> We nce Number — <br /> U.s.EPA.ID Number <br /> 1Eb.Alternate Facility(or Generator) <br /> U <br /> w Facility's Phone: } <br /> Month Day Year <br /> 18c SignatureofAlternale actny OrGerarator, <br /> .ef <br /> Z <br /> Hazardous'.Waste Report Managment Method Codes(i.e_codes for hazardo. 8ing system$) 4. <br /> - ,Cn4aiE"b' :i et,x _ 't,nwed in iiam 182 Month Day Rear <br /> 20.Dasignatod Paciify'Ovmar or Oparalor:(;enttilytlon of receipt of haz'arduU3"'c.:a_ �1;i;e a"" �"pt`9 <br /> Printedryped Natty, <br /> L'�G•L_ � i/ J <br /> DESIGNATED FACILITY TO GENERATOR <br /> EFA Form 8700-22(RV.2-05} Previoue edi cons era obsolete.:* <br />