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19- 1.1 <br /> / ate of California—Environmental Protection Agency <br /> rm Approved OMB No.2050-0039(Expires 9.30-99) See Instructions on bac age 6. Department of Toxic Substances c <br /> - lease print or type. Form designed for use on elite(12 f pewriter. Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Documert,tJo. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFEST !Q IL, 101010 112121111401 `1 6 of 1 EES4 <br /> 3. Generator's lin and M <br /> Name aiddress A. State Manifest Document Number <br /> 4bl2J�r k wL5-1 2379089 <br /> rg j V-4 s- Q�lA 5�3 L' 3. State Generator's ID- <br /> Ln I <br /> h <br /> L <br /> 4. Generator's P one( �1) MCI?- <br /> c14 <br /> 5..Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved-] <br /> T EVERGREEN ENVIRONMENTAL SERVICES <br /> 0 <br /> CAD 9 8 2 4 1 3 2 6 2 ° Tr°nspart°� Phone (800)972-5284 <br /> C? 7. Transporter 2 Company Name 8. US EPA ID Number 'E. State Transporter's ID[Reserved.[ <br /> I�Q F..Transporter's Phone. <br /> mu 9. Designated Facility Nome and Site Address 10. US EPA ID Number :G. State Facility's ID <br /> O0 d EVERGREEN OIL,INC. C A D 9 81 01. 81 81 71 41 11 81 <br /> Z 6880 Smith Avenue H. Facility's Phone <br /> OZ <br /> �0 Newark,CA 94560 ICIAID191810181817141118 (510) 795-4400. <br /> h Q12. Containers 13. Total I4. Unit <br /> V <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) pe Quantity WI/Vol I. Waste Number <br /> NzG!L rtn• state <br /> x <br /> 3 NON-RCRA RDOUSWASTE,LIQUID 0 0 1 TIT p Sib G EPA/alone <br /> C N b -- State <br /> a°Do E <br /> � R EPA/Other <br /> Iq A a State <br /> o T <br /> O EPA/011ier <br /> R <br /> s <br /> State <br /> LU d. <br /> Z EPA/Other <br /> V <br /> w <br /> V) J. Additional Descriptions for,Materials Listed Above K. Handling CoderfbrWastes Listed Above <br /> Z <br /> O <br /> 0 <br /> LU <br /> • w <br /> Q - <br /> Z 15. Special Handling Instructions and Additional Information <br /> 0 2q7, <br /> l� <br /> 24 Hour Emergency Response Telephone No.:CHEMTREC 1-800-424-9300 Invoice# = <br /> Z DOT ERG 171 WEAR PROTECTIVE EQUIPMENT Sales Order#1Jbi°83? _ <br /> U.1 <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are Fully and accurately described above by propriship ing name and are classified,packed, <br /> e' <br /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government'regulotions. <br /> ' J If I am a large quanti generator,I certify that I have a pro ram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economical)' <br /> J ty g <br /> a practicable and that f have selected the practicable method a treatment,storage,or disposal currently available to me which minimizes the present and future threat to human heals <br /> N and the environment;OR,if I am a smaquantity generator,I-have made a good faith effort to minimize my waste generation and select the-best waste manogemer t,method that is <br /> available to me and that I con afford. <br /> OPrinted/Typed Name Signature Month Day Ye, <br /> Z � 1� D o <br /> U.1 T 17. Trans orter Acknowle ement of Receipt of Materials <br /> R Month Day Ye <br /> —7 <br /> LU p Print ped am Si not <br /> W "s /� 01�1N Z U. <br /> w 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> TPrinted/Typed Name Signature Month Day Ye <br /> r N R <br /> ta,) 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> L <br /> I 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Ye- <br /> DO NOT WRITE BELOW THIS LINE. <br /> DISC 8022A(1/99) White: TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS <br /> EPA 8700-22 To: P.O. Box 3000, Sacramento, CA 95812 <br />