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* 4�64.12 <br /> � i <br /> Please print or type.(Form designed for use on eliteT�-Pitch)typewriter] Form Approved.OMB No 2050-003 <br /> UNIFORM HAZARDOUS 1 nerato ID Number /} 2.Page 1 of 3.Emergency Response Phone 4.Manifest TrackinNumber <br /> WASTE MANIFEST �,�/l—rj , ,_600-424-s3o0 0023-9 0 3 9 0 JJ K <br /> 5.Generator's Name and Mailing Addres'sz- � `M Generator's Site Address(itdinerent than mailing address) <br /> llv yL.6,Trans oner 1 Company Name U.S EPA 10 Number <br /> sgvergreen Environmental Services CAD982413262 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> Evergreen Oil, Inc. U.S.EPA ID Number <br /> 6880 Smith Ave. <br /> Newark,CA 94560 <br /> Faciliys Phone: 510-795-4400 CAD980887418 <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and P king Group(if any)) No. Type Quantity WLNOL 13.Waste Codes <br /> l�� /�1lt �i1 �/�1A Ge/r6Ci <br /> o r <br /> /zlo3, <br /> ZC 1 >a oa3 o <br /> a��/eG OiG. � Dwt 3n <br /> ����- � / er. i <br /> l[°j✓OGi� 3S <br /> 14.Special arMliiiInshuctions andAdtlilional Information <br /> zg <br /> 98 X17 ( �o_v ss/6sh o��r <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and amnately described above by the proper shipping name,and are classified,packaged, <br /> 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 <br /> Exporter,i unity that the contents of this consignment conform to the fauns of the attached EPA Acknowledgment of Consent. <br /> I ceNy that the waste miniminhan statement idenfified in 40 CFR 262.27(a)(if I am a large quanfity generator)or(b)(81 am a s II quan' nerator)is e. <br /> Generata mfs Pnnted7TYped Name Signa Mayh Day Year <br /> / fCX, C L/�L 7d C7+ <br /> F16.intemami—Shipments ef <br /> Z LJImport to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): <br /> Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 P yped Name <br /> Month Day Year <br /> r9 <br /> Tra porter 2 PnntedRyped Name S' atom <br /> Month Day Year <br /> I-- <br /> } 18.Discrepancy <br /> 18a,Discrepancy Indication Spam <br /> ❑ Quantity ❑Type ❑Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number. U.S.EPA ID Number <br /> J <br /> U <br /> LL Faciliys Phone: <br /> w 18c.Signature ofAltemate Facuy(or Generator) Month Day Year <br /> Q <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> W <br /> a 1 2. 7. <br /> 4. <br /> 1 20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item laa <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />