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Stats of California—Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9-30-99)See Instructions on back,&e 6. Department of Toxic Substances Contrd <br />Please print. or type. Min," designed for use on elite f 12 -pi ewriter. Sacramento, California <br />LO <br />M <br />n <br />(4 <br />W) <br />0 <br />m <br />�J <br />Q <br />I <br />Z <br />C. <br />tV <br />O <br />co <br />ao <br />N <br />0 <br />W <br />w <br />a <br />'Z <br />w <br />U <br />LU <br />N <br />Z <br />0 <br />a <br />Uj <br />w <br />99Q <br />Z <br />0 <br />a <br />Z <br />Q <br />DO N&W -TE BELO*'fHIS NE. <br />DTSC 8022A (1/49j White:' TTSDF SEN&S THIS COPY TO DTSC WITHIN 30 DAYS. <br />EPA 8700-22 P <br />To: .CJ. Box 3000, Sacramento, CA 95812 <br />I . Generator's US EPA ID No. Manifest Documen o. <br />2. Page 1 <br />Information in the shaded areas <br />UNIFORM HAZARDOUS <br />is not required by Federal law. <br />WASTE MANIFEST ® <br />-7 1 <br />EES4 <br />.,S*to' ame a� Moi ing� rass <br />j <br />Y�q <br />A. State Manifest Document Number <br />yy Q <br />. JrYI Q6ii �r ® ®.®� <br />B. State Generator's 1-2348777D <br />4. Generator's Phone 2017)"92st—Aagrel <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C: State Tronsporter.'s ID (Reserved.] <br />EVERGREEN ENVIRONMENTAL SERVICES CA019181214-1113121612 <br />D. Transporter's Phone Sr1® 070– 284" <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter's ID [Reserved:jW <br />F. Transporter's.Phone -- <br />9. Designated Facility Name and Site Address 10, US EPA ID Number <br />G. State Facility's ID <br />EVERGREEN OIL, INC, <br />I C At DI 91810181 8L 714111: 8 <br />" Facility's Phone <br />6880 Smith Avenue <br />Newark CA 94560 1 C1 Al01918101818171411181(51'0) <br />795-4400 <br />11. US DOT Description (including Proper Shipping Nome, Hazard Class, and ID Number) <br />Containers <br />13, Total <br />Quantity <br />14. Unit <br />Wt/Vol <br />I. Waste Number <br />No <br />o. <br />Tye <br />a. <br />State. <br />EPA/ None <br />NON-RCRA HAZARDOUS WASTE, LIOU® <br />0 <br />TIT, <br />E <br />N <br />b, <br />State <br />EEPA/Other <br />Tc. <br />State <br />O <br />"EPA/Other <br />R <br />d. <br />State <br />=A/0t1.r t <br />- J. Additional Descriptions for Materials Listed Above. <br />- <br />K. Handling, Codes For Wastes <br />Listed Above <br />-. <br />a. <br />15. Special Handling Instructions and Additional Information: <br />24 Hour Emergency Response Telephone No.: CHEMTREC 1.800-424-9300 <br />'` Invoice <br />DOT ERG 171 1- . WEAR PROTECTIVE EQUIPMENT <br />Sales Order # <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and ore classified, packed, <br />marked, and labeled, and ore in all respects in proper condition for transport by highway according to <br />applicable international and national government regulations. <br />If I am a large quantity generator, I certify that I have a program in place to reduc F e volume and toxicity of waste generated to the degree I have determined to be economically <br />have d to the and future threat to human health <br />practicable and that 1 selected the practicable method of treatment, storage, pose( currently avaifabfe me which minimizes present <br />and the environment; OR, if I am a small quantity generator, I have made a goo fo' effort- my waste generation and select the best waste management method that is <br />available to me and that I can afford. <br />Printed ped Name t �.��� <br />Signatu <br />s <br />Month Day Year <br />Nom► lCl <br />d ®.� <br />R17. <br />Transporter I Acknowledgement ement of Receipt of Materials <br />A <br />Printed ped Name <br />�vti.t.b <br />Signa#e <br />Month DayYear <br />s <br />0 g C <br />0 <br />1 I' Trans rter 2 Acknowledgement of Receipt of Materials <br />R <br />Printed/Typed Nome <br />Signature ff <br />Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />L <br />. <br />20. Facility Owner or O rotor Certificoiion of receipt of hazardous materials co d etas rioted in Item i9. <br />TPnnt <br />,Typed ams - .Si at <br />Month /Day Year <br />v <br />umonwifest <br />rd rA .16{( <br />U^ <br />DO N&W -TE BELO*'fHIS NE. <br />DTSC 8022A (1/49j White:' TTSDF SEN&S THIS COPY TO DTSC WITHIN 30 DAYS. <br />EPA 8700-22 P <br />To: .CJ. Box 3000, Sacramento, CA 95812 <br />