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*,i3anerator,rna4 a c 0:DTSC,P.O.any 4m,Sacramento,CA S& )400 W"hih 3D days <br /> Please print or type.(Form designed for use on elite(12-p_.q typewriter.) Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2 <br /> UNIFORM HAZARDOUS Page t of 3.Emergency Response Phone 4.Manist Tracking Number <br /> WASTE:MANIFEST CAR000059972 1� 1.8013-4249300 10 ,089444653 JJK <br /> 5.Generator's Name andMailingAddress Generators Site Address(if different than mailing address) <br /> 2U0:,E5ORADO ST <br /> STOCKTON CA S520S <br /> Generators Phone: MQ-9324758 <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 U.S.EPA ID Number <br /> EVERG41%EN OIL, INC. <br /> 6880 SM AVE. - CADOMS7418 <br /> NEWARK -CA 94M <br /> Facility's Phone::, <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers11.Total 12.Unit <br /> HM and Packing Group(if any)) <br /> No. Type Quantify Wt./Vol. 13.Waste Codes <br /> 0 1.UN2810,T0XIC LIQUIDS,oR13ANIC,N.C1,S,,5.1, II Q�1S- S51 <br /> UN2809,WASTE MERCURY,8, 111 181 D(kU8 <br /> X1 <br /> DIV! <br /> n _ <br /> 14.Special Handling Instructions and Additional Information /J/J� ��j�/Z�• ����2� <br /> A.71451 ERG.153-9bl /ri'��SG�G 7O Document# <br /> 1 71296 ERG 172-9b21X 121951 <br /> 15, GENERATOR'SIOFFEROR'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 labelediplacarded,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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator Offeror's Printed/Type ame Sionature Month Day Year <br /> _J 16.Intemational Shipments <br /> r— Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W17,Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 P'ntedRyped Name a Month Day Year <br /> QTransporter 2 PrintedrTyped Name Signature Month Day Year <br /> tY <br /> t- <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space El Quantity ❑Type ❑Residue ❑Partial Rejection Dull Rejection <br /> Manifest Reference Number: <br /> F}„ 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> Lo 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,ano recycling systems) <br /> 01 2. 3. 4. <br /> tq 1 1 -4)qI HIL- I HIL�l <br /> 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials co ered by the manifest except as noted in Item 182 <br /> PrintedTfyped Name Signature Month Day Year <br /> S'fC'r. sI I a 1,-271 it <br /> EPA Form 8700-22(Rev.3-05) Previous editionif are obsolete. ��`,ahlfi= F-4CILI i V TO DEC-TINA-110N ST>f.i E (IF R EOUIRED` <br />