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DTS'C- 00,9�: .. x. 740 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.G erator ID Number / 2 Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST �Z(/ ?� a 1-800-424-9304 002390336 JJ K <br /> S.Generators Name and Mailing Addre � [,/14 <br /> -PF 112-0 <br /> y/ Generators Site Address(if different than mailing address) <br /> T7 0/ 74-4;1 0I�� <br /> /- <br /> GrferafoesP oh <br /> 6.Trans rter 1 Company Name U.S.EPA ID Number <br /> s9vergreen Environmental Services CAD982413262 <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. <br /> Newark,CA 94560 <br /> Facilitys Phone: 510-795-4400 CAD980887418 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(d any)) No. Type Quantity WtNol. 13.Waste Codes <br /> 2 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Speclal Handf g Instructions andAdditional Information <br /> 15. GEN ERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classiied,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or b)(if I am a small quantity generator)' true. <br /> G rators/ONemrs Pdnted/T Name Signa Month Day Year <br /> re,9 o r { F/AZkY-r o <br /> —A 16.International Shipments <br /> ❑Import to U.S. Export from 11.1;. Pan of entry/exit: <br /> Transporter signature(for exports only): Data leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> � <br /> Transporter 1 Printed(Typ me Signature Month Day Year <br /> C VI <br /> �sQ <br /> a <br /> QTransporter 2 Pri /Typed Name SignatLA Month Day Year <br /> h- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> wr+5'TG R Ecef w O RS I.!/157E F -+��f n Z-4(Z"os, ,•%o-�s- -S3//DW I~ <br /> G {A%est Reference Number <br /> 18b.Alternate Faality(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facilitys Phone: <br /> W 1ac.Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> h <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C3 ,. / ' ,Lf/ Z. 3. 4 <br /> 20.Designated l}Faaar�lity Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item laa <br /> PrinUWryped Name Signature Month Day Year <br /> Of 116 1 oil <br /> EPA Form 8700-22(Rev.3-05) Previous ons are obsolete. NATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 10533.2159 <br />