COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

Dit+ rh,na (FnrmdeSl nedfor imennalit.-1`17-nifnh)tvni.....n.-r Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED r--'�CILITY TO DESTINA9 ON STATE (IF C� EQUIFIED) UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 1=800-424-9300 4. Manifest Tracking Number 1 JJK WASTE MANIFEST I eM- 4OM; �i-,J j 1 006661378 address) 5, Generator's Name and Mailing AddresGenerator's Site Address (if different than mailing/ Generator's Phone: J y--74-1,� 6. Transporter 1 Company Name U.S. EPA ID Number Evergreen Environmental Services CA®982413262 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address Evergreen Oil, Inc. U.S. EPA ID Number 6880 Smith Ave. - Newark, Ca. 94560 CAD980887418 Facility's Phone: 510-795-4400 ge 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste -Codes No. Type HM and Packing Group (if any)) Quantity Wt.Nol. Uj 3. 4. 14. SpecialHandling Instructions and Additional Informa�tio�n�, 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAclmowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity gener or) o (b) (if I am a small quantity generator) is true. Gener, erors Prints ped Name Sign tura v Month Da Year ram J a— 16. International Shipments ❑ Impart to U.S. Export from U.S. Port of softy/exit: Transporter signature (for exports only): Date leaving U.S.: � 17. Transporter Acknowledgment of Receipt of Materials 1&j O Transporter 1 Printed/Typed Name �,� Sign gpxe� Month Day Year MTransporter 2 Printed/Typed Name Signature Month Day Year t-- 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number J V Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year B z 55 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) ® 1 2• 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedlTyped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED r--'�CILITY TO DESTINA9 ON STATE (IF C� EQUIFIED)