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1 Generator's US EPA ID No 2 Pape 1 1 3 Document Number <br /> NO of NH— N° _ 1 3 9 4 <br /> a Generators Name and i AddressEES 19 <br /> Y, <br /> S7 <br /> < ; Generator s Phone <br /> 5 Transporter Company blame 6 US EPA ID Number 7 Transporter Phone <br /> EVERGREEN ENVIRONMENTAL SERVICES <br /> CAD982413262 800-972-5284 <br /> a Designated Faality Name and Site Address 9 US EPA ID Number 10 Facility's Phone <br /> Evergreen Oil, Inc <br /> x 6880 Smith Avenue <br /> Q Newark,CA 94560 CAD980887418 510-795-4401 <br /> 13 <br /> 11 Waste Shipping Name and Description 12 Containers TotaUnit <br /> 11 <br /> N No T OuanWWo[ <br /> IE <br /> R a <br /> A fWate <br /> -Hazardous waste, liquid 0p1 TT S G <br /> a n of <br /> R b <br /> h <br /> 15 Special Handling Instructions and Additional Information Handling Codes for Wastes Usted Above <br /> 1t 11b <br /> Profile <br /> Do not Ingest X33 6 <br /> Wear protective clothing Invoice <br /> In case of emergency call CHEMTREC 800-424-9300 Sales Order Si���Y/ate <br /> DOT ERG 171 <br /> v� Loc47`•or.- /.2// Co _ <br /> 16 GENERATOR'S - <br /> Pnntedfryped Name Spnature <br /> TMonth Day Year <br /> j/ <br /> A S� QN /� S <br /> N .: <br /> s 17 <br /> P <br /> Printed/Typed Name Signature <br /> R / Month Day Year <br /> A / r 9y' <br /> 18 Discrepancy indication Space <br /> 4 <br /> F <br /> A <br /> C <br /> F! <br /> 'L- <br /> Print edfr Name Signature <br /> Monts Day Year <br /> 1 ___" _�v I � <br /> WHITE—ORIGINAL(Return to Generatorl_.,—YELLOW--TSDF(Rota!"Cory PINK—4A POR'1ER COPY GOLDENROD—GENERATOR'S COPY <br />