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i <br /> NON-HAZAR©OUS ' ' Generator's US EPA ID No <br /> 2 Page 7 3 Document Number <br /> WASTE MANIFEST;�,° of <br /> 1 NH-N° 1311 <br /> 4 Generators Name and Mailing Address <br /> —0 EES 19 <br /> t /�ti�Iytlf <br /> I "21 y s A:rC4 <br /> Generators Phone 9 <br /> 5 Transporter Company Name 6 US EPA ID Number 7 Transporter Phone <br /> EVERGREEN ENVIRONMENTAL SERVICES <br /> ' CAD982413262 800-972-5284 <br /> 8 Designated Facility Name and Site Address 9 US EPA ID Number ID Facility's Phone <br /> ' Evergreen Oil, Inc <br /> 6880 Smith Avenue <br /> Newark, CA 94560 <br /> E CAD980887418 510-795-4401 <br /> 1 11 waste Shipping Name and Description <br /> N 12 Gontarnere 13 14 <br /> E Total Unit <br /> R No TvrLq Quanti WtNol <br /> A <br /> T an-Hazardous Noante, liquid <br /> ' <br /> Wate and of 001 TT 33 <br /> b G <br /> i15 Special Handling Instructions and Additional Information HandlingCodes for wastes <br /> listed Above <br /> 11a 11b <br /> Profile # <br /> Do not ingest <br /> Wear protective clothing <br /> In case of emergency call CHEMTREC 800-424-9300 Invoice 7�� tom/ <br /> DOT ERG 171 Sales Order <br /> ' v!� Iac/tT,ur / /apt Stv"ti-II WIX 7cuk_7c--- C4 <br /> 16 GENERATOR'S CERTIFICATION I certify the materials described above on this rnandest are not subleq to state or federa repoiatiorts for reporting proper disposal of Hazardous Waste <br /> Printed/Typed Name Signature <br /> ' T A( {/�� ) TL <br /> N {� / /►7 i O� �j � Month Day Year <br /> v II 3� 43 <br /> P spor <br /> 17 Transporter Admomewledgement of Receipt of Materials`1 1- r <br /> 0 Printed/Typed Na <br /> Signature <br /> R <br /> T <br /> R [. Pp tom!/ Month Day Year <br /> u9 30 9� <br /> 18 Discrepancy Indication Space <br /> ' F <br /> A <br /> C <br /> I <br /> L <br /> I <br /> T <br /> 19 FacilityOwner or Operator Certification of receipt of waste ttlatertala taovereIeta ` in itea t8 x w` a <br /> Pnnted/Typed Slgnature <br /> ` {— r Month Day Year <br /> WHIT:—ORIGINAL(Return to Generator) 4ELLOW—TSDF(Retain Copy)/ PINK—TRAM PORTER COPY GOLDENROD—GENERATOR'S COPY <br />