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ease print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1. ra ID Nu 2.Page 1 of 3.Emorgency Response Phone 4.Manifest Tracking Number WASTE MANIFEST -- 1 1-800-424-9%: w.r O 12390105 JJ K 5.Generator's Name and Mailing Address-�/e / >` "� ]� Generator's Site Address Cit different than mailing address) rhrator s Phone: ? 6.Transporter 1 Company Name U.S.EPA ID Number Evergreen Environmental ervices CA0982413262 7.Transporter 2 Company Name U.S.EPA ID Number t 8-Designated Facility Name and Site Address U.S.EPA ID Number Evergreen Oil, Inc. 6880 Smith Ave. Newark,CA 94560 FadWs Phone: 51 f�-7gr,�— 400 vW 8 ga. 9b.U.S.DOT Description(including Proper Sh' Name,Hazard Class,ID Number, —10.Containers I.Total 12.Unit 13.Waste Codes HM and Packing Group Cd any)) NO -TY-p;d Quantity Wtivol, 1 10 Z 2. W tD t 3. 4. 14.Special Handling Instructions and Additional Info n 15. GENERATOR'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 classified,packaged, marked and labeledlplacarded,and are in all respells in proper condition for transport accon5rg to applicable imemational and national governmental regulations.If export shipment and I am the Primary Exporter,I cartify that the contents of this consignment conform to the terms of the attaclhed EPA Acknowledgment of Consent. I certify that the waste minimization stelemerd identified in 40 CFR 262.27(a)(d I am a large Quantity generator)or(b)(d I am a FW quantity generator)is Genneratorsl0+feror`s Pnntmffyped Nance Signa M"" Day Year J 16.International Shipments i- ❑Import to U.S ❑Export from U.S. Port of entry/exit . Z Transporter signature(for exports only): h Date leaving U.S.. W 17.TomporterAdmowledgment of Receipt of Materials Transporter 1 Print ped Name Signature / Monnly D y^ or/� QTransporV2 Pririted(TypefName i Month Day Year 18.Nieaeparxy _.._.�...__.,._.____ ...-- •-__.___A 18s.Discrepancy IndicarW Space E? 9 [:]Type ❑Residue ❑Partial R.*tbn ❑Full Rejecliah Manifest Reference Number. 18b.Altemete Facility(or Generator) U.S.EPA ID Number J_ V FoalM' s Phone _ W 16c.Sitinalure of Alternate Facility(or Generator) -.__..._.'....,.._..,_ ___ _ •-� —___.—r __ Month Day Year Z I Vj19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) A 1. 2. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Nem 18a� PWnted/iyperl Name -- —— -- Signature Month Day. Yew_! MA c.....,07nn oo ro ..