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4 <br />11 <br />Please print or type (Form designed for use on elite (Ah) typewriter.) Form Approved. OMB No. 2050-0039 <br />UNIFORM HAZARDOUS 11. GWwretoj ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />14, Manihat Tracking Number <br />0 0 6 6 612 41 JJ K <br />WASTE MANIFEST <br />1 <br />1-800-474-9300 <br />S. Generator's Name and Mailing Address Generators / Generator's She Address (it different than mailing aaddddrreess <br />((p//-�'o�,."���,�,��^�^'S�goz�/!�' <br />�r �1!.�c..Yi� •Ji/i��ii /'L+,�L- - <br />' � ry riGJ <br />�ifs✓V gs3710 <br />� <br />6S 9 /6V <br />Generators SS's - 8�� 09� <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Evergreen Environmental Services CAD982413262 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />B. Designated Facility Name and Site Address U.S. EPA ID Number <br />Evergreen Oil, Inc. <br />6880 Smith Ave. <br />Newark, Ca. 94560 CAD980887418 <br />Facility's Phone: 510-795-4400 <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Gass, 10 Number, <br />10. Containers <br />11, Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group(it any)) <br />Quantity <br />WtNol. <br />zz <br />Z <br />2. <br />w <br />t7 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information{ - <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping dame, and are classified, packaged, <br />marked and labeledlpiacardild. and are In ail reapads In propar ohndition for transport acwrdlng to applicable inlamabonaland national govemmental n gulagons. II export shipmenl and I am the primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowfedgment of Consent. <br />I cenAy that the waste minimization statement identified in 40 CFR 262.27(a) if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />GeneratoeslOBeroVs PdnWffypA Name Signature Month Day Year <br />,,I i <br />III <br />Zi <br />16. International Shipmelits 11 Import to A. ❑Export from Pon of enirylexit: <br />Transporter signature (for expods only): Date leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />Signa Mowntthh Day Year <br />Transporter 1 miledrryped Name <br />to <br />ZR <br />Transporter PrintedRMonth Day Name Signature Y Year <br />F <br />♦ <br />18. Discrepancy <br />18a. Discrepancy indication Space ❑ Quantity [IType El Residue ❑ Partial Rejection DWI Rejection <br />Merriest Reference Number: <br />186. Ahemale Facility (or Generator) U.S. EPA ID Number <br />d <br />U <br />LL <br />Facility's Phone: <br />Wlife. <br />Signature of Alternate Facility (or Generator) Month Day Year <br />Z <br />LD <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />4. <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as rated in Item 18a <br />PrintedrItyped Nam WAR---- .. - - North y ear <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />