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77 .�— Tn "'� i .':J -_"' - _-� r—-i^ - , -^-rte- -�-„` -�---•c- s�-.�.� <br /> 'L <br /> 1 k <br /> F . "` 1 Generator's US EPA ID No 2 Pagel 3 Document Number <br /> 0 ( (AZ OURS of _ -y <br /> BASTE`1A— � E -�I f 1 NH r 2 17 Q$ <br /> f4'Gefinerator's Name'and Madrng Address ,. EES 19 <br /> I tic • <br /> x477tf11�'�I t�! <br /> Generator's Phone <br /> 5 Transporter Company Name 6 US EPA ID Number 7 Transporter Phone 4 <br /> 9 EVERGREEN ENVIRONMENTAL SERVICES ` <br /> CAD982413262 800-972-5284 <br /> E <br /> 8 Designated Facility Name and Site Address 9 US EPA ID Number 10 Facility's Phone <br /> Evergreen Oil, Inc <br /> 6880 Smith Avenue <br /> G Newark, CA 94560 CAD980887418 510-795-4401 <br /> E 11 Waste Shipping Name and Description ,' <br /> N _ 12 Containers 13 14 <br /> R Tol Una <br /> No Type Ouant <br /> ar Wt/Voll <br /> ' <br /> T Non-Hazardous waste, liquid <br /> a Water and oil <br /> R 001 TT [`� j j G <br /> b <br /> 15 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 /> DOT ERG 171 <br /> 16 GENERATOR'S CERTIFICATIQN Xceitrfy th$materials described above oq this rriNiitest are not subject to-1f'ate or federalrepulatio s for gporUnQ prppei dnpasal of HazaRiiirs Waste°t <br /> Printed/Typed Name Signature <br /> T <br /> R Month Dy Year r <br /> N _ 0_ EAti,'�.. C) _ O <br /> S 17.Tra�Isp<trter+4ckrwwfedgemerlt of Receipt pf Matdrlal3' - t, -A:,Rv n�i�-s��T <br /> OPrinted/Typed Name Signature <br /> R i <br /> llu c o e'E' Kk i`yr�cl h c ���e d ." l Month D Year <br /> 18 Discrepancy indication Space <br /> r <br /> F <br /> A <br /> C <br /> I <br /> L <br /> ..� <br /> wro s 5 Fe�itlty Qwner or Opeiatgr t ettiticatEon of lrscetpt of waste matetfais cbve� <br /> f, Printed/Typod Name Signature <br /> Month Day Year <br /> WHITE—ORIGINAL(Return to Generator) YELLOW—TSDF(Retain Copy) PINK—TRANSPORTER COPY GOLDENROD—GENERATOR'S COPY <br />