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frlcase ;:,err o`� n iod N� i��u o��flj a� P. ,pox 400 Sacramento,Ca.95812-oWltllin 3O C'IavSkFen Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generate,ID Number 2 Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST G`/''0fi�?3S-Z-73•2-<�' 1 1-800-424-9300 1004475099 JJ K <br /> 5.Gerziretw's Name and Mailing Ad&esl/,Re/ � � • .�!" e,S/� Genemrys Site Address(if drImeni than mailing address) <br /> "-331-7/7y Gs �Civ. +75z-*ee <br /> Generator 4 phrare: <br /> 6 Transporter i Company Name U.S.EPA ID Number <br /> -NTAI <br /> qppVin'r <br /> 7.Traneporter2 pony Nerve U.S.EPA IDNumbar <br /> 8.Designastc Facility Name and Site Address U.S.EPA IO Number <br /> Evergreen Oil, Inc. <br /> 6880 Smith Ave. <br /> Newark,Ca 94560 CAD980887418 <br /> Faci s Phoria: <br /> 92_ Sb U.S.DOT Description(including Proper Shipping Name,Humid Class,ID Number, 10.Containers 11 Tea^ 12.Unit 13.Waste Codes <br /> HM and Packing Greop(d any)) ,.•��..}� / �/T!' No. Type Quantify MNot, <br /> IY. X, t A�i93U77�x /� '�Srar+r,AT� s0�o V'0-.> %t""'-' OL1 <br /> w X 2.!/j13o7'7x/lH�'itl34S�(eGfStrE",$/r .1(d.S��j '' 10`1114�r 'sE•/1.,m� <br /> 3. <br /> 4. <br /> -F- <br /> 14 atH�eimglmtruchursand AdditionalInmirmalon <br /> .�ri/F ERG 1 <br /> 96 -y '3- - 94r a 2 <br /> Use appropriate P E / ^S 9d-Z llsPiv u// 3 <br /> 15, GENERATOR'S7OFFEROR'S CERTIFICATION: I hereby declare Bat the mments of this consignment am fury and accurie"described above by the proper shipping rime,and are dastifiexl..Packaged, <br /> matted and IabeledlplataMed,and we in all respect in Kept,condition la transport according to appinnife international and national governmental regulations.a export shipment one I am the Primary <br /> Exporter,I caddy met the contents of this consignment conform to the terms of Bre atuched EPAAcknowledgmem of Consent. <br /> I caddy that the waste nunimumfion etalnmes identified m w CFR 262.27(a)lif I am a large Quantity generator)or(b)(it i am a small puantiry,genpramt is car:. <br /> Ginome'SIOBerofs Prinled/typed Name $gnatua Month Dai Yea <br /> MCI gow4�2MAN <br /> 16.International Shipments <br /> i ❑how in U.S ❑Error,Som U:5. Pod of entrylexB: <br /> Thumportmsignature(for experts only)- Date leaving U.S.: <br /> Oc 17.Transporter Acknowledgment of Receipt of Materials <br /> WW Tmmponer 1 m edRyped Name Signa. /f/�f Mopmh Dap yea' <br /> O <br /> NZ <br /> ¢ <br /> Transporle.2 Prinled?yped Name Sig^atcrr. Montt Dal Year <br /> a <br /> H- <br /> 1 18 Osoiepancy <br /> 183.@srsepancy mdicilbn Space ❑ Quantity ❑Type ❑Residue. ❑Partial Rejection ❑Fue Rejection <br /> Manifest Reference Number <br /> 18b.Alternate FackAy(0,Generator) U.S.EPA ID Number <br /> ..4 <br /> U <br /> LL Faolldy'sPhone� <br /> w 18c.Sgnmure ofAltemalo Family(or Generale•) Mont, Day Year <br /> a <br /> z <br /> Z^ I9.Hazardws Waste Repot Management Method!Codes(i.e..codes for hazardws waste matnent disposal and recycling systems) <br /> 0 1 2 3. a <br /> 20.Dasignaled Facicy,Onmr or Ope:a;o'.Cenlrsalion of receipt of hazardous materials covered by tie mantles'.except as noted in Rem t&n <br /> Pfinud'IyuldNand, Signature Month Day Yea: <br /> EPA Form 8700�22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILITYTO DESTINATION STATE (IF REQUIRED) <br />