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pi.- nnnl nr hmp fFnrm Hm.t1MP<d fnr me;a nn olhF (12-nitnhl rypawriter.) <br />Form Approved. OMO No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3.05) Previous4dilions are obsolete_ <br />DrS&NATED FACILITY TO DESTINATION STATE OF REQUInED <br />Z00 'd Ed ZE :10 NODI 1102-6Z—HV <br />UNIFORM HAZARDOUS <br />1.Oeneralor ID Number <br />2. Page 1 of <br />3. Fmergenoy Response Phone <br />4 MenlfestTracking Number <br />K <br />wAS f'E MANIFEST <br />1 <br />1-800-424-9300 <br />1 006561378 eJ FJ <br />5. Generetors Name end Malling Address n/1 `` Generators S$eAddress (If diff nt t an mail' address) <br />' �/ Gam' '`ma -O <br />Generators Phone: cS —7�ffs = 7j •�JO/ <br />6. Transporter 1 Company Name U,S, EPA ID Number <br />Evergreen Environmental Services CAD982413262 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8.DeaignmdFacility Nameand Site Address Evergreen Oil, Inc. U4. EPA ID Number <br />6880 Smith Ave. <br />Newark, Ca. 94580 CAD980887418 <br />Facllitys Phone: 510-795-4400 <br />gL <br />9b. U.S. DOT Description (ncluding Proper Sl 1ppi(g Name, Hazard Class, 10 Number, <br />10. Containers <br />11. Total <br />12. Unit <br />1g, Waste Codes <br />No. I <br />Type J <br />HM <br />and Packing Group (If any)) <br />Quanury <br />WLNGI_ <br />Alf <br />6Z> <br />2J?� <br />a <br />w <br />2. <br />O <br />3. <br />ti <br />4. <br />14. Spedal Handling Instructions and Additional Infcrmallon <br />15. GENFRAT0111510FFEROR'S CERTIFICATION: I hereby declare that the conlenrs of t1ils consignment are. fully and accurately cescrted above by the proper shipping name, and ani classified, packaged, <br />marked and labeledlpfawrded, end ere in all respects In proper condition for transport according to applicable International and nat)onal governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the anached EPA Acknowladgmant of Consent. <br />I certify that the waste minim¢ation statemant identified In 40 GFR 262.27(a) (f lama large quanUly gene r) o (b) Qf I am a small quantitygenerstor) is true. <br />Cene erors Printe ed Name Sign Wre Mon�N DayYear <br />16. International Slllpnneftts: i:; .;,>.,_ ❑ Import to U.S. ❑ Export from U.S. Port of entrylaxit <br />Transportarsignalurf (foriexp8rts:orily),- ;' ;,. Dale lowing U.S.: <br />17. Transport9rAcknowledoftntofR&AiptofNblarialsLLI <br />Transported Pfintedrit,pedName%` Month Day Year <br />g <br />r <br />Transporter 2PrinledlTypedName Slgnalure Month Day Year <br />18, Discrepancy <br />18s. Dlscrepancy Indication Space ❑ Quantity ❑ Type ❑ Reeldue ❑ Partial ReJecUon ❑ F0 Rejection <br />Manifest Reference Number. <br />1 Bb. Altemate Facility (or Generator) U.S. EPA ID Number <br />U <br />LQ <br />Facilitys Phone: <br />W <br />18c. Signature ol`Altemata Facility (or anerat0r) <br />Month Day Year <br />a <br />a <br />1 Ef. Hajrdous Waste Report Management Method Codes (i.e., codas for hazardous waste treatment, disposal, and recycling systems) <br />� <br />1 <br />2. 3. <br />4. <br />20. Designated Facility Omer orOperalor. Certification of receipt of hazardous metedels covered by the manlfesl except as noted in Item 18a <br />Anted yped Name. Signature Mon Day Year <br />o '-6 111 <br />EPA Form 8700-22 (Rev. 3.05) Previous4dilions are obsolete_ <br />DrS&NATED FACILITY TO DESTINATION STATE OF REQUInED <br />Z00 'd Ed ZE :10 NODI 1102-6Z—HV <br />