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R <br />VA <br />Please print or type. (Form designed for use on elite (12 -pitch) types <br />UNIFOREMANIF�OUS �' mlorlQN, ^6r <br />WASTE MANIFEST <br />5. Generators Name and Mating Address <br />'den afato <br />one: <br />- <br />6. Transporter 1 Company Name <br />Evergreen Environmental Services <br />7. Transporter 2 Company Name <br />I• <br />0 <br />W <br />0 <br />LUz <br />0 <br />d. Qesionated Facftlly Name and Site Address <br />Evergreen Oil, Inc. <br />6880 Sli-lith Ave, <br />Newark, CA 94560 <br />cin ane AAAA <br />1 <br />0 <br />Form Approved. OM No. 201 <br />3ency Response Phone 4. Manifest Tracking Number <br />1-800-424-9300 0 0 2 3 9 0 2 7 9 JJ K <br />(s SiteAddress (if different than malting address) <br />CAD982413262 <br />U,S. EPA 10 Number <br />1 <br />U.S. EPA ID Number <br />~ r`A r)cin nPM7AI R <br />ga <br />HM <br />9b. U.S. DOTDescripldr, (including Proper Shipping Name, Hazard Class, ID Number, <br />andrPadting Group (if any)) <br />10. Containers <br />11. Total <br />Quantity <br />12. Unit <br />W1Nd, <br />13. Waste Codes <br />No. <br />Type <br />es <br />fy <br />w 18c. <br />d <br />z <br />11Y\ <br />2-40 <br />19. Hazardous Waste Report Management Method Codes {Le„ codes for hazardous waste treatment, disposal, and recycling systems) <br />Q <br />1. L413. <br />4 <br />20. Designated Facility Owner er(f dperalon Certification of receipt of hazardous materials covered by the manifest except as noted In €Tem 18a <br />2. <br />Printedffyped Name, Signature Month Day �Year <br />4, <br />14. 5 aClal tlanerng insaucuons ane Huumurm InFurrnduurr <br />15, GENERATOR SIOFFEROR`S CERTIFICATION: I hereby duciare that the contents of this consignment are fully and accurately deserted above by the proper shipping name, and are classified, packaged, <br />marked and labeledfpiacaAad, and are In all respects In proper condition for transport according to applicable Intemafional and national governmental regulations. If expel shipment and I am the Primary <br />Exporter, I carfify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmanl of Consent. <br />I cedify that the waste mtnimizafien statement IdenfiSed in 4C CFR 232.27(a) (if I am a large quanikr genera or (h) (ill am a small quantity generator) is true. <br />Generators! rocs PrintedFFYPed Namg Slgn Month pay Year <br />16. international Shipments <br />� ❑ Import to U.S. ❑ Export form U.S. Puri of entrylexll: <br />2 Transporter signature (for exports only): Date leaving U.S.: <br />17. TransporlerAclmowt mart of Receipt of Materials <br />TranspoderI Porde d Name Signature �1� <br />D <br />O� z Transporter PrintedFryped Name Si lure Day Yea <br />Q <br />F <br />tYA corm tsll7U-a jKray. 3-ub) Previous wits 11s are OD501ele. <br />.ErCSfGNATED I I Y 1U `JE,SIIINAI IVIM aIAJIt ttt- r}cUttrrrcr✓/ <br />18a, Discrepancy Indicallon Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejecllen ❑ Fuu Rejection <br />Manifest Reference Number. <br />18b, Altemale Facility (or Generator) U.S, EPA I Number <br />es <br />fy <br />w 18c. <br />Faculty's Phone: Month Day Year <br />Signature of Altemato Facility (or Generator) <br />d <br />z <br />19. Hazardous Waste Report Management Method Codes {Le„ codes for hazardous waste treatment, disposal, and recycling systems) <br />Q <br />1. L413. <br />4 <br />20. Designated Facility Owner er(f dperalon Certification of receipt of hazardous materials covered by the manifest except as noted In €Tem 18a <br />Printedffyped Name, Signature Month Day �Year <br />tYA corm tsll7U-a jKray. 3-ub) Previous wits 11s are OD501ele. <br />.ErCSfGNATED I I Y 1U `JE,SIIINAI IVIM aIAJIt ttt- r}cUttrrrcr✓/ <br />