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Please print or type. (Form design, <br />UNIFORM HAZARDOUS 1 <br />WAS'%E MANIFEST I <br />5, Generators Name and Mailing <br />for use pn elite (12-M,uh) typewriter.) <br />nerator ID Number 2. Page t of <br />dress <br />Services <br />Form Approved. OMB No. 2050-00: <br />Iency Response Phone 4, Manifest Tracking Number <br />1 -800 -QA -mm 1001828287 JJK <br />'s Site Address ('rf different than mailing address) <br />EPA ID Number <br />CAEM413M <br />EPA ID Number <br />7. Transporter 2 Company Name <br />8. Designated Facility Name and Site Addres <br />5 Evergreen Oil Inc. <br />U.S. EPA ID Number <br />GM Smith Ave. <br />Newark, CA 940 <br />510-795-4" <br />CAD 7418 <br />Facility's Phone: <br />9a. 9b. U.S. DOT Description (including <br />Iroper Shipping Name, Hazard Class, ID Number, <br />10. Containers 11. Total <br />Quantity <br />12. Unit 13. Waste Codes <br />WtNoi. <br />HM and Packing Group (if any)) <br />No. T� <br />(JAI <br />-30 <br />?�! <br />LU <br />Uj <br />3. <br />�,....,a —ifiod n kanpri <br />15. GENERATOR'SIOFFEROR'S CERTi K AI Mn: 1 nereuy ucuaio �,a, w,� •• - — - to applicable international and national govemmentai reguiaoons. c,r n, s,,, ,,, ^• - marked <br />and Iabeledlplacarded, and a in all respects in proper condition for transport according PP <br />Exporter. I certify that the contents of is consignment confork262.27(a) <br />s of the attached EPA Acknowledgment Cons a small quantity generator) is We. <br />I certify that the waste minimization statement identified In 40 (W I am a large quantity generator) q g Month Day Yr <br />Signatu I e <br />Generator si0tferorMotTlyped Name A <br />7_::: <br />16. International Shipments ❑ Export from U.S. <br />Port of entrylexit: <br />❑report to U.S. pate leaving U.S.: <br />IF— <br />? Transporter signature (for <br />17. TransporterAdmowied <br />s only): <br />of Recetp of Materials <br />18, Discrepancy�� <br />I Be. Discrepancy indication Space <br />181c. Alternate Facility (or Generator) <br />J <br />V <br />tdi Facility's Phone: <br />W 18c. Signature of Alternate Facility <br />a <br />Z <br />N19. Hazardous Waste Report Man, <br />UJ 1 <br />Q ' <br />20. Designated Facility Owner or C <br />V%Wl (TVped Name <br />'01/ <br />,,,liii ❑ Full Rejection <br />11 Re �artial Rejection <br />Quantity � Type <br />M ifest umber: / t <br />PAID Numbe��xj` o 10 <br />codes for hazardous <br />Method Codes (i.e., waste treatment, disposal• and recycling systems) <br />3. <br />2. <br />of hazardous materials coveted by the manifest except as noted in item 18a <br />Certification of receiptS onature <br />Ell <br />DT -TJ ; E (IF FtE(t <br />�4�3t�ESiG. <br />