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Mar, 6, 2012 9: 20AM HEINZ '_,A No, 3333 P, 4 <br /> e s t or type,(Form designed for use on elite(12-, )typewnler) FormrtPProvea.Urvid Ivo,iuou-uvea <br /> UNIFORM HAZARDOUS t.Genera r 2.Page 1 of 3.Emergency Response Phone 4,Manitest7racking Number <br /> WASTN&kN~ � 1 1-800-424-9300 <br /> 1006661369 J J K <br /> 5.Genetalofs Name and Melling Address ` Generator's Site Address(if different than mailing address) <br /> Generator's Phone: <br /> 6.Transporter 1 Company acme U.S.EPA ID Number <br /> Evergreen Environmental Services CAD982413262 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address U.5,EPA ID Number <br /> Evergreerii Oil;[no.- <br /> 6880 <br /> no.6880 Smith Ave. <br /> Newark,Ca.94560 CAD980887418 <br /> Facilit es Pnome: 510-795.4400 <br /> oa, 9b.U.S.ROTDe4cnp8on(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit f8,Waste Codes <br /> HM and Parking Group(il any)) No. Type Quantity Wt.tvol, <br /> 3. <br /> 4, <br /> 14.5 Gal Hanaling Instructions and AdditiO4 In orrmbof <br /> 15. GENERATOR'SIGFFEROR'8 CeTSFICATiON: I hereby declare Ihat the contents of VJ$consignment are fully and accuvatety desatbed above try the proper shipping name,and Are GAWled,packaged, <br /> marked end Iabeledlplacarded,and are in all respects in proper Cond6on for VTISPort aco*ing to applicable international and national govemmsntal reguladons.If expos Shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignmant conform to the terms of the abched EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 4tl CFR 26227(a)(if I am a large quantity genaratw)or(b)(dl am a small quanta generator)is true. <br /> Generatgr el(?Ifero s Pr nt yped Name Signature Month Day Year <br /> �f �^ -1 <br /> -j 16-International Shiprnonts <br /> rrLJ Import to U.S. Export from LIZ. Port ofentrylmdl; <br /> z Transporter signalure(for exports only): Date leaving U.S.: <br /> 1Z 17.Transporter Acknowledgmant of Reoelpt of Matedals <br /> Tra spotter Printedlryped Name S Month Day Year <br /> X Transporter 2 Panted ped Narre Slgnalura Month Day Year <br /> ce <br /> N <br /> 18-Discrepancy ��11 <br /> 18a.Discrepancy Indloaticn Space Quant ty LJ Type Residue ElPartial Rajeriion ❑Full R.aiecllon <br /> Maniteat Reference Numlrar: <br /> 18b.Ailemaie Fadlity(or Generator) U.S.EPA ID Number <br /> Fadfiys Phone: — - — - Nanta Day Yea, <br /> W 18c.SIgnalureolAltornate acllty orGenerelgr) <br /> I <br /> z <br /> N19.Hazardous Weste Report Management Method Codes G.e..Codes for haaardous wasia Veatmanl,disposal,and recycling systems) <br /> LU <br /> 1. �l <br /> �1 l 4 <br /> 0 � y 2. <br /> 20.Deri tiled Facility Ormer or Operator:CoMiWflon of racedl of hwrOws mnteriats ob"red by the mantfest except as ruled in Item 18a <br /> Prnta djTyped Name SlgnatuTo omh Day year <br /> trill Q t, u ffff/( &/'�4 1/ <br /> EPA Form B700.22(Rev.3-p5) Previous editions are obsolete- DESIQNATED FACILITY TO DESTINATION STATE(IF REQUIRED. <br />