Laserfiche WebLink
Plaaca nrint nr firm (Fnrm desinned for use on elite (12-oitch) tvnewriter.) <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIC,NK6 ;O FA.OU7Y 70 DESTINATRON STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />1 <br />3. Emergency Response Phone <br />1-800-424-9300 <br />4. Manifest Tracking Number <br />1 JJ K <br />WASTE MANIFEST <br />eM,(, ; jam j� <br />00666 378 <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailinjaddress) <br />151Xff A57 <br />Generator's Phone: S,769 <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. Designated Facility Name and Site Address Evergreen Oil, Inc. U.S. EPA ID Number <br />6880 Smith Ave. <br />Newark, Ca. 94560 CAD980887418 <br />Facility's Phone: 510-795-4400 <br />9a <br />91b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />1'`�J'%Aft'�j9�i0%>'r?°i�GfO!!./4��•`'s.ti�.� <br />. <br />a <br />2. <br />LLJ <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />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, <br />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 <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity gener or) c (b) (if I am a small quantity generator) is true. <br />Geneperor's Printe ped Name Sign ture Month Year <br />��Dayy�� <br />Ham �i <br />-J <br />l; <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name Sign . Month Day Year <br />QTransporter <br />2 PrintedfTyped Name Signature Month Day Year <br />r-- <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑Partial Rejection Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />C3 <br />Facility's Phone: <br />w <br />18c. Signature ofAltemate Facility (or Generator) <br />Month Day Year <br />B <br />05 <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />® <br />1. <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Ba <br />Printedffyped Name Signature Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIC,NK6 ;O FA.OU7Y 70 DESTINATRON STATE (IF REQUIRED) <br />