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VI <br />/j t-/ '-) 0 <br />Pleese nrint,ar rvoe. (Forth desioned for use on efile (12 -pkat) typewriter.) <br />EES -28 0 <br />Pom1 Approved, OMB No. 2050.0039 <br />ERA=oIM700.22 (Rev. 3.05) Previous editions are obsolete. <br />DESIGNATED FACILi -1'Y1'0 DESTINATION STATE (IF REQUIRED) <br />000 'd Wv X0:60 NOW 11OZ-81-'IIID <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page i of <br />J. Emerew+cS Rosponoe Prgne <br />no Numb <br />4, Mano t Tra7"62746 <br />WASTE MANIFEST <br />CAD982413262 <br />1 <br />1800-424-9300 <br />0 0 5 6 2 7 4 6 JJ <br />S. Generelor's Name and MoOmg Address Generators Site Address (if different Nen melift adore* <br />EVERGREEN ENVIRONMENTAL SERVICES 6880 Smith Ave. <br />P.O. Box 248 Newark, Ca. 94560 <br />Genermes Phone: 610-795-4400 <br />B. Tiansporter 1 Company NBMI U.S. EPA ID Number <br />EVERGREEN ENVIRONMENTAL SVIVICES CADS824132152 <br />Transposer 2 Company Name U.S. EPA 10 Number <br />8. Designated Facility Name and She Address U,S. EPA ID Number <br />EVERGREEN OIL, INC. <br />6830 Smith Ave. Newark, Ca. 94560 <br />510-795-4400 CAD980887418 <br />Fadia Phone: <br />ga <br />ab. U.S. DOT Description (including Proper Shipping Name, Hazard CAm.10 Number, <br />10, Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Pecking Group (f any)) <br />Guawy <br />WIJVOI. <br />o <br />1. <br />NON-RCRA HAZARDOUS WASTE, LIQUID <br />1 <br />17 <br />G <br />134 <br />WASTE ANTIFREEZE <br />j Q <br />e1r <br />2. <br />c� <br />3. <br />4, <br />14. Special Handling instruclmns and Additional Information <br />PROFILE # Exempt INVOICE # <br />DOT ERG# 171 WEAR PROTECTIVE CLOTHING SALES ORDER # <br />15. GENERAT0R'S/0PF00lT$ CERTIFICATION: I hereby declare that the content: of this conslgrnwl are tuiy acture described above by Ne proper shipping name, and are classified, packaged, <br />marked and labeled/pieearded, and are in all respects' conditiotlfortrarsrporl according to applicable' national governmental regulations. If capon shipment and I am the Primary <br />Exporter, I certify that the contents of this con sig t conform to the terms of the attached EPAAcknowletiq t <br />5issrnall <br />I cerury that the waste minimirafion ataremam Werrd in 40 CFR 262z7(s) (f I am a large quentiy genera or quantity generator) is tare. <br />Generato' Offerors r rinlocyped Name Sig Month Day Year <br />,.a <br />f- <br />16. Intemationel Shipments <br />❑ Import to U.S. ❑ Exporthowl P, d entry/exit: <br />Tronsponersignsture (for exports only):Ieaving U'S': <br />Cr. <br />17, Trsmponer Aclo wleogrrent of Receipt of Materials <br />Trani pod Printed yped Name { frig Month Day <br />T <br />CL <br />yYear <br />� o <br />ronaD 2 PtinteOfTyped ems glgn Month Day Year <br />t- <br />18. Discrepancy . <br />I� <br />18x. Discrepancy Indication $Decd by ` �T a i�-j y t.�$eal� [ y Fjaction <br />`�� <br />b2il (- I ) Manifest Reference Number; �.Gef✓'t r <br />1 lb. Amite Facility (or Goneraw r) U.S. EPA ID Number <br />J <br />v <br />1.6 <br />Facaity's Phone: <br />w <br />18c. Signature of Atten ale Fsgi'ky (or Gortaralor) Month Day Year <br />Q <br />, <br />19. waste Report <br />Hazardous Management Method Codes (.e., codas for hazardous waste treatment, disposal, and recycling systems) <br />W <br />t•/ / / <br />2. 3. <br />4. <br />Facia fitly <br />20. Designated Facy owner ficahon of coipt Of hazardous materials covered ntte0 <br />rmted/ryp Signature Month Day Year <br />ERA=oIM700.22 (Rev. 3.05) Previous editions are obsolete. <br />DESIGNATED FACILi -1'Y1'0 DESTINATION STATE (IF REQUIRED) <br />000 'd Wv X0:60 NOW 11OZ-81-'IIID <br />