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D T 6F (s.�- 0'.' ; Please print or type.(Form designed for use on elite(12-pitch)typewriter.) EES-4 Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST L 0000-1 1 a 1 1-800-424-9300 003779319 JJ K 5.Generator's Name a�npp Mailing Address Generator's Site Address(if different than mailing address) (/-H�,G Irr- 02-0 / 7]OJ( /Arr Dr-rhshu%U 0r- J/0C JC Ca 91 LJO Generator's Phone: a 09' -f 6.Transporter 1 Company Name U.S.EPA ID Number Evergreen Environmental Services CAD982413262 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designa Facill Name a S e Address U.S.EPA ID Number ver`areen�1�, Inc. 6880 SMITH AVENUE NEWARK CA 94560 CAD980887418 Facilitys Phone: 510-795-4400 9a. 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(d any)) No. Type Quantity Wtivol. 13.Waste Codes 0 1NON-RCRA HAZARDOUS WASTE, LIQUID 001 TT G & i I., 2. w ra 3. 4. 14.Special Handling Instructions and Additional Information PROFILE # 5`13 INVOICE DOT ERG# 171 WEAR PROTECTIVE CLOTHING SALES ORDER # 7 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully,and accurately described above by the proper shipping name,and are classified,packaged, 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAdknowiedgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(JI am a small quantity enerator)is true. Generatoes/Offeroes Printed/Typed Name Sign re Month Day Year C 1 O 7 1 O 16.International Shipments Z ❑Import to U.S. ❑Export from .S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: LU 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Pnntedlfyped Name Signature Month Day Year CL Cn o zQ Transporter 2 Printed/Typed Name Signature Month Day Year t- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ U LL Facility's Phone: W 18c.Signature of ARemate Facility(or Generator) Month Oay Year Q Z rn 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 3 2. 3. 4..5 - 1 20.Designated Facility Owner or Operator.Certification of receipt of hazardous matenals covered by the manifest except as noted in Item I 9 Pnntedrryped Name (!� S SignatuMonth Day Ye re s EPA Form 8700-22(Rev.3 0 ou Prev s editions are obsolete. LA& 1 1-71041 DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) 10330.1076