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Please print or type. (Fyrm designed for use on elite (12•p kh) typewriter.) EES -4 <br />6TH- OOS9G- 0548 <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev, 3-05) Previous edfions aro obsdel9. I dFAIGNATED FACILITY TO DE INATION STATE (IF REQUIRED) <br />10320.1423 <br />UNIFORM HAZARDOUS "Generator O tlumber <br />2. Page i of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST C4bito a(y <br />1 <br />1-800-424-93x0 <br />1. 003779016. JJK <br />5/en4; rName and Mabg Address Generators Se.eAddress (ddfierent than mailing address) <br />K4' 64 -Nr - E/ STAGG Sub. <br />5-415- F,-4-iti-� 9-7s ->fowL— us, 9rta3 <br />Generator'sPNne: . t <br />6. Transporter 1 Company Name U.S. EPA ID Numter <br />Evergreen Environmental Services CAD982413262 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Desr9naFacNty Name and re Address U.S. EPA ID Number <br />vergreen OilI, Inc:. <br />6880 SMITH AVENUE <br />NEWARK CA 94560 CAD980887418 <br />FacV es Phone: 510-795-4400 <br />9a. <br />9b. U.S. DOT 0esaip5ca (ndu&ng Proper SKcppng Name, Hazard Vass, 10 Number, <br />i8. Cmtalners <br />11. Total <br />12 Unit <br />13, Waste Codes <br />No. <br />Tyre <br />HM <br />and PaftgGroup (dany)) <br />Quantity <br />MN01. <br />o <br />NON CAA HAZARDOUS WASTE, LIQUID <br />001 <br />TT <br />G <br />Z� <br />SL <br />Qt L <br />x <br />J <br />ilii <br />2• <br />c� <br />3. <br />4. <br />14. Spedal Hand5ng Instnrct>ans and Addrfwnal Information <br />PROFILE # INVOICE#, yr -3 Ybo <br />DOT ERG# 171 WEAR PROTECTIVE CLOTHING r SALES ORS 9# <br />15. GENERATOR'S11OFFEROR'S CERTIFICATION: I hereby deciare thattha contents of this consignment are, f&j and zoant0l described above by N proper sKrpftg name, ad are dassTed, pack2ged, <br />marked and tabe'edlplacwded, and are In a7 respects In proper cond:ton for transport according to applicable Intemational and natonal governmental reglatiens. Itexport shipment and 1 em the Primary <br />Exporter, I certify that the contents of the canslgnment conform to the teens of the attached EPA Acknov,'edgment of Consent. <br />1 certify Thal the haste mk*ntzation statement IdenMed is 40 CFR 26227(a) (d I am a larga quant'ty generator) or (b) (dl am a sma7 quanGiy genrator) e. <br />Genera;orsloffe rs Prnte&Typ Name S:grmture Month Day Year <br />- <br />E22 O/w w i�C�t..3 0 .?Y <br />16.In%,natlonalShipments,, <br />: - : ❑ Import to U.S. ❑ Export from U.S. Port of entTy/844 <br />�r <br />F- <br />Transporter s'rgrtature (iu 6pbrts omy}: 20 leaVng U.S.: <br />ix <br />17.TrartsporterAckrovdedgmentofRe*tofMalaria's <br />Transport r 1 Prntedrfyped Name SrnaNre h'.onlh pay Year <br />O <br />nQZ. <br />Trensperter 2 Printedrryped Name S'gna Month Day Year <br />18. Discrepancy <br />18a. Disuepancy tndcat)cn Space ❑ Quanbiy El Type ❑ Partial Re,1.0c, <br />❑ Reed. ❑ Ful Reectan <br />Manfesl Reference Numbe,: <br />18b. Ah:emate FaciEty (or Generabnr) U.S. EPA ID Number <br />V <br />tai. <br />Fadityys Phone: <br />180. Signature ofNternaleFad6ly(or Generator) <br />6'onth Day Year <br />d� <br />z <br />• <br />h19. <br />Hazardous 1Wasta Report Management McBrod Codes p.e, codes for hazardous waste treatment, dsposal, and recycil g systems) <br />0 <br />1. <br />2. <br />ated Fm., d O sner or Operator. Cert `cation of receipt of hazardous materials covered by tt:e mari%st except as noted in Item 18aped <br />Name ) 5gratvre Month NY ,Year <br />E <br />EPA Form 8700-22 (Rev, 3-05) Previous edfions aro obsdel9. I dFAIGNATED FACILITY TO DE INATION STATE (IF REQUIRED) <br />10320.1423 <br />