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, f <br /> tT + <br /> I� <br /> /`�� " �''a 1 Generator's US EPA ID No 2 Page 1 3 Document Numbert"ANO <br /> f}V$ ofN1�— O + 704 <br /> ST � ,"m 1 <br /> 4 Generator's Name and Mailing Address4j Z EES 19 <br /> 4 1'7114 rv\cat„ S <br /> i 1 �,�t 5 �ti tat Ejeai 6N\ C r 73 G <br /> 5�a� � � v ►� C � , <br /> ' Generator's Phone <br /> 5 Transporter Company Name 6 US EPA ID Number 7 Transporter Phone <br /> i+ EVERGREEN ENVIRONMENTAL SERVICES <br /> ' CAD982413262 800-972-5284 <br /> 8 Designated Facility Name and Site Address 9 US EPA ID Nvmber 10 Facility's Phone <br /> ' Evergreen Oil, Inc <br /> 6880 Smith Avenue <br /> G Newark, CA 94560 CAD980887418 510-795-4401 <br /> ' t ! 11 Waste Shipping Name and Description 12 Containers 13 14 <br /> TotalUnit <br /> FES No I Type OuantiWt/vol <br /> rq a <br /> Non-Hazardous waste, liquid r <br /> R Water and oil 001 TT W-?J U G <br /> 14 b <br /> k <br /> 15 Special Handling Instructions and Additional Information Handling Codes for Wastes Listed Above <br /> 11a 11b <br /> a , <br /> Profile# <br /> Do not ingest ,�����p <br /> Wear protective clothing Invoice <br /> in case of emergency call CHEMTREC 800-424-9300 Sales Order <br /> DOT ERG 171 <br /> ' <br /> 18•GENFATOR'S CERGATtON,13 ceilfy.#he materials decrbed abve on hs ` Iair <br /> t _gap I <br /> Qp <br /> ntecypedName o' 4 <br /> Signature <br /> T 44 AR Gv:,� Month Day, Year <br /> ' p` 1Trdii4AAtEeit?Acl�npti, edgegnro)� I"tohllalei�alss ' <br /> O Pnnte&TypW Name Signature <br /> R <br /> TMoE V Cr' Q '" 1 r I' � r Y�'t '�` � nth G Year <br /> A <br /> ,;s 18 Discrepancy Indication Space <br /> F <br /> I <br /> o p1° t'a's1a rpa°�er(&t:�' ve"'rre�tiyb� a <br /> PdntedlTyped Name! Signature " <br /> Month Day Year <br /> WHITE—ORIGINAL(Return to Generator) YELLOW—TSDF(Retain Copy) 1 PINK, COPY w! GOLDENROD—GENERATOR'S COPY <br /> 7*5 n, <br />