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ft30.. 070.2 <br /> Please print or type.(Form designed for use on elite(12•pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> 1 Ge torIDNumber 2.Pae 1 of 3.Emergency Response Phoneanifest Tracking Number <br /> UNIFORM HAZARDOUS �L.��-' a r9 h' po 9 <br /> WASTE MANIFEST 1 1-800-424-93007002390306 JJ K <br /> 5.Generators Name and Mailing Address 2_1 Generator's Site Address(if different than mailing address) <br /> Generators Phone: <br /> 6.Trans iter 1 Company Name U.S.EPA ID Number <br /> SEvergreen Environmental Services CAD982413262 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPAID Number <br /> Evergreen Oil, Inc. <br /> 6880 Smith Ave. <br /> Newark,CA 94560 <br /> Facility's Phone: 510-795-4400 CAD 980887418 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.CcrLai ners 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 3.Waste Codes <br /> C=7T <br /> Z 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Acial,H, ling Instructions and Additional Information <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping narre,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.If export soipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment f onsem. <br /> certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)9V(if I am a small quantity generator) a. <br /> Gen r'sl0fferofs Printed/Typed Name Signal Moran Day Year <br /> L IV e-: Zyla-vwlo <br /> J 16. emaoonal Shipm is11 <br /> �. ❑Import to U.S. Export from U.S. d of entrylexit <br /> Transporter signature(for exports only): Oats leaving U.S.: <br /> 17.Transporter A edgment of Receipt of Materials <br /> Transporter�Pyped � Signature Mon Day f <br /> O <br /> C <br /> co <br /> ZZ Transpo er 2 PrinteciTyped Name Sig re Month Day• Year <br /> K <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facility's Phone: <br /> W i8c.Signature of Alternate Facility(or Generator) Moran Day Year <br /> Q <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. / 7_I 2. T. <br /> 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> r <br /> tedlTyped Name Signa Mon;h Day Year <br /> S�� 6 1 a-6 1017 1 <br /> EPA Form 8700-22(Rey,3-05) Previous 'r bons are obsolete. t6VENATED FACILITY TO DESTINATION STATE(IE REQUIRED) <br /> 10573.1749 <br />