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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1'.G eralor ID Number Q? 2.Page 1 of 3.Emergency Response Phone r006660754 anifest Tracking Number WASTE MANIFEST Z•�O ! � 1 1-800-424-9300 JJ K 5.Generators Name and Mailing Address Generator's Site Address if different than mailing address e eral rSPhone: _/� ��• �j ZY�v ��6iG��'�l(�1` ��y y 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.Designated Facility Name and Site Address Evergreen Oil,Inc. U.S.EPA ID Number 6880 Smith Ave. Newark,Ca.94560 CAD980887418 Facility's Phone: 510-795-4400 ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity wtNol. M 2. w 3. 4. 14.Special Handling Instructions and Additional Information —7,0/ 6l#/-- 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 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 cerfily that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I cedify that the waste minimization statement identified In 40 CFR 262.27(a)(if I am a large quantity generator)or( (if I am a small quantity generator)is true. Generalorsl fferoes Printed/Typed Name Signature Month Day Year 7S o lot -t A A/& k) A� 12 [AA 11 116.International Shipments ❑Import to U.S. El Po entry /exit:rt from U.S. Port of en lexit: Transporter signature(for exports only): Date leaving U.S.: LW 17.Transporter Acknowledgment of Receipt of Materials t2 Transporter 1 dnted/Typed Name A S' re Month Day Year CL ZZ Transpoftbr 2 PrinledlTyped Name Signature Month Day Year W- i- 18.Discrepancy rt�� 18a.Discrepancy Indication Space ❑ Quantity ❑Type ElResidue ❑Partial Rejection LJ Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number U .<1 Facility's Phone: w 18c.Signature of Altemate Facility(or Generator) Month Day Year Q z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 T— 2 3, 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Ilem I Be Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)