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EES-3 <br /> Please ont-or type.(Form designed for use on elite(12•pltct y aemiter.) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator lD Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAD982413262 1 1-800-424-9300 002388029 JJ K <br /> S.Generators Name and Mallin Address Generators Site Address(if different than mailing address) <br /> EVERGREEN ENVIRONMENTAL SERVICES <br /> 6880 SMITH AVE., NEWARK CA. 94560 CAD982413262 j <br /> !. Generator's Phone; 510-795-4400 <br /> 6.Transporter f Company Name U.S.EPA ID Number <br /> `h EVERGREEN ENVIRONMENTAL SERVICES <br /> 4 7,Transporter 2 Company Name U.S.EPA ID Number <br /> + I <br /> r <br /> 8.Designated Facili Name and Site Address U.S.EPA ID Number <br /> EVEEGREEN OIL, INC. a <br /> E 6880 SMITH AVENUE NEWARK CA. 94560 CAD980887418 j <br /> Fadllt's Phone: 510-796-4400 <br /> 9a. 9b.U.S.DOT Description(nduding Proper Shipping Name,Hazard Class,ID Number, 10.Confalnem 11.71aw 12.Unit 13.Waste Codes <br /> NM and Packing Gawp(If any)) No. Quantity w1No4. <br /> I <br /> j; 0 1' NON-RCRA HAZARDOUS WASTE,LIQUID (USED OIL) 221 <br /> 001 : TTI AOG <br /> I. <br /> I' <br /> 1. 3. <br /> l <br /> I ' <br /> i <br /> 4. <br /> t <br /> 14.Special Handling Instructions and Additional Information <br /> bOT ERC,# 171 WEAR PROTECTIVE CLOTHING WHEN HANDLING MATERIAL <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully n accurate] described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are In all respects in proper condIt on for transport according to applicable In r atonal an natlonal governmental regulailons.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 EPAAcknowledgme t (Co <br /> rea <br /> I certify that the waste minimiza0on statement Idendfled In 40 CFR 262.27(a)(if I sin a large quantity generator) (b)(If I a a small quantity generator)Is true. <br /> 1. Generators lferor's PrintedlTyped Name' Signature Month Day Year <br /> jI 141016 <br /> -J 16;Inter nationatS Ipments <br /> ,I F ❑Import to U.S, ❑Export from U,S, Polo'entry exlf: <br /> Transporter signature(for exports only): Date ving U.&: <br /> 1rc�port*Acknowledgment of Receipt of Materials <br /> Trarwport-r.l. _tedfrypedName Signature Month Day Year <br /> LI F-41 W <br /> r p9Rer:2 pfintecl Cl Name Signature Month Day Year <br /> •�` '18:pl�crepaitCji'•`;;° I <br /> :{ ..j 0 Isdfe gticiY Indk'0m Space <br /> ❑ Q"flity 11 Type ❑Rasldue ❑Partial Re)ectlon ❑Full Relecdon <br /> ( .. ;�'18�•� '+=• ••�`••-- Manifest Reference Number. <br /> . _ @ie Ffdj+(arQer�rator) U.S.EPA Number <br /> ., K1. j <br /> `?; �gc SlgnApr)e'.a. tefriata Faor Generator) Month Day Year <br /> ManagBnlent,Method Codes(i.e„codas for hazardous waste treatment,disposal,and recycling s stoma <br /> 7. <br /> "; c's+'20,t)e ¢pat9d Fclilfy: eAa:DperalbrJ'C ' Gf racelpt of hazardous materials covered by the manifest except as n 1 I m 18a <br /> phntatltTypejme Signature — Mcnth Day— Year: <br /> 7`Pre low dM6hd'are.abs eta.. : + <br /> • # 1 +'ysr"xa<' .;..rig.• DESIGN D FACILITY TO DESTINATION STATE(IF REGIIJIRED). :. 1 <br />