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r <br />EES -4 <br />-- -- r-- ---- -- _,.� a ---- a Farm Annmved- OMB Nn- 2050-0089 <br />r roaao <br />yuan v, err.. �• .r.,,, .•.« ....• .�.... .... ,...a a.� r.._..r yr...........i - <br />UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone a. Manifest Tracking Number <br />S- - 007039392 JJ K <br />waM MANIFEST <br />5. Ge erator's NjZne and MaliigAddress Gsmrdws Site Address (If different than mailing eridras) <br />GenetawsPhone: ZOS� l- Zb 41 <br />6. Trans r 1 Company Name U.S. EPA ID N=W <br />Evergreen Environmental Services CAD 982413262 <br />i <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 />EVERGREEN OIL, INC. <br />6880 SMITH AVE., NEWARK CA. 94560 <br />510-795-4400 CAD980887418 <br />Fadfi s Phone, <br />98. <br />9b• U.S. DOT Description (including Proper Shipping Name, HaZwd Class. ID Number, <br />10, C r alners <br />11. Total <br />12. Unit <br />13 Waste Codes <br />No. <br />Type <br />HM <br />and Paddn g Group Cd may)) <br />Quantity <br />v ivol. <br />c <br />NON-RCRA HAZARDOUS WASTE, LIQUID <br />001 <br />TT <br />� <br />G <br />2Z3 <br />w <br />2 <br />I <br />� <br />( r <br />I <br />3. <br />E <br />I <br />4. <br />I <br />14 -Spacial Handling Instructions and Additional Information <br />PROFILE # invoice 033 L)" <br />DOT ERGO 171 WEAR PROTECTIVE CLOTHING Sales Order # <br />15. GL'NERATOR'SIOFFEROR'S CERTIFICATION. I hereby declare that the Contents ofthis oonaEgnnetnt ars tiny and ewuretely desorilxd above by Una proper shiPPing name. end are dassiiiect! ..1. Sed1 . <br />`dnary <br />marxed and labeledlptacerded, and are in all respects In proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am tt>e'•I <br />Exporter, I certify that the contents of tltie mraignmem conWm to the term of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement Idemi0ed In 40 CPR 28227(x) Crf I ern a large qu Mly generelor) or (b) of I am a small quantity gen 'is true. <br />S�neture y Year <br />Generatorsltxferors Primddrfyped Name . Month Da <br />� b LILL <br />,"r <br />16. btternatiord Shipments <br />❑ import to U.S, Export from U.S. Port of armylexit <br />= <br />Transporter signature (for exports only): Date leavh9 U.S.: <br />17. Im"ortar Admowie4ment of Receipt of Mate M <br />Name Signature Month Day <br />Transporter 1 A jYear <br />Q' <br />Transporter 2 Pdntedlfyped Name Spnature Month Day Year <br />W <br />H <br />18. Discrepancy <br />rr�� <br />lea, Discrepancy Indication Space ® Quantity ❑ Type ❑ Residue ❑ Partial Rejection L.J Full Rajection <br />Manifest Reference Number. <br />18D. Ahemate Facility (or Generator) U.S. EPA ID Number <br />V <br />La <br />Facilly's Phone; <br />1d <br />18C. Signature of Alternate Facility (or Gentratoo <br />- <br />Month Day Year <br />Z <br />A� <br />19. Mazardoue Woo Report Management Method Codes (i.e.. codes for hazardous waste tregimenL disposal. and recycling systems) <br />2 <br />3, <br />4. <br />20.-Deergnatod-FeOility'Owner-orOpemator. GenbficatiWs of tecoiptot haLeraoos materials covered by the mEbbstexceptas n din Item lea <br />P&Wffyped Nam ire stn Day Year <br />EPA Form 3700-72 MV. 3.09) YreviOus eamOn3 Sri: 00t30r9 - DESIGNATED F AQILJTY k E3 ®=STINATIUr4 5 kA -1 t'• tit, YiCldt,liC =u2: <br />Zoo 'a ala 1 s: Z i QOM 1 1 oz-oz-Znr <br />