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'lease print or type.(Form designed for use on elite(12-pitch)11ter.) Form Approved,OMS No.205t)-OU39 UNIFORM HAZARDOUS &.NMI,0�_IA66 2.Page 1 of 3.Emergency Responsg Phone 4.Manifest Tracking Number WASTE MANIFEST �%' 1 1-800 4 4-9300 003336016 JJK 5.Generators Name and Mailing ddre Generators Site Address(if ditiereni than mailing address) 249 Gene tors hone: <-��j B.Transpor�r��yN InvlronmentalServices U.S.EPA ID Number B6er�t C CAD982413262 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site AddressEvergreenoil, Inc. U.S.EPA ID Number 6880 Smith Ave. Newark,CA 94560 CAD980887418 Facilittfs 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 Pa ng Group(ti any)) No. Type Quantity Wt.N0I. 3 ad- 4. 14.Special H Ii g Ins s and Ad "onala I rma ition e,7 /-13 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately desodbed above by the proper shipping name,and are classified,packaged, marked and labeledlplacarded,and are in ail respects in proper condition for transport armrtling to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,l certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. i certify that the waste minimization statement identified in 40 CFR 262.27(x)(f I am a large quantity generator)or(b)(if I am a small quantity generator)is e. GeneratotslOffemrs PdntedlTyped Name Signature * Month Day Year r ��Z, �� f0' 2-S j 16.1ntemational Shipments ❑Import to U.S. ❑Export from U.S. Port of entrylexit: Transporter signature(for exports only): Date 1%v ng U.S.: t17.Transporter mast of Receipt of Matedalssporter 1 P yped Name/ Signature Mon bay Year fi§W::: 1 /0 1 CTran er 2 Prin yped Name nature �th bay Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number 5 i Facility's Phone: j 18c.Signature of Altemate Facifity(or Generator) Month Day Year is 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) i 1 2 3. 4. 20,Designated Facility Owner or Operator:Certiticaficn of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrtntedlTyped Name Signature Month Day Year 'A Form 8700-22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)