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lease prinfbr type. (Form designed for use on elite (92- pay <br />UNIFORM HAZARDOUS 1. Wrator IQ Numb <br />WASTE MANIFEST <br />5. Generators Name an� !� A�dfreTs�s <br />Aw <br />p� , �V r <br />eeta <br />ntors fho e: ` / <br />6. Transporter 1 Company Name <br />Evergreen Environmental Services <br />Facility <br />Evergreen Oil, Inc. <br />6880 Smith Ave. <br />Newark, CA 94560 <br />ran lAC AArtrt <br />;�6 <br />Foran Approved. OMB No. 2050-0039 <br />age 1 of 3. Emergency Response PF -one 14. Manifest Tracking Number <br />1 1 1-800-424-9300 1 002390279 J J K <br />1.4,f4f ,Generator's Site Address (if different than mailing address) <br />U.S. EPA ID Number <br />CAD982413262 <br />U.S. EPA ID Number <br />r.AnQJQnAA7A1 A <br />ga <br />HM <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />and Packing Group (if anyj) <br />14. Containers <br />11, Total <br />Quantity <br />12. Unit <br />Wt.Nol. <br />13. Waste Codes <br />No. <br />Type <br />24 0 <br />2. <br />3, h <br />4. <br />14.5 eaal nancnng msrruouons arwmummrid, mwnuauvu <br />--1 7 <br />-'3 C--.7 <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 name, and are classed, 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 certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity general ) or (b) (d I am a small quantity generator) is true. <br />Generators/ ror s PrintedlTyped Namq U Y Sign a Month Day Y <br />tI/1AV I ! o <br />j 16. International Shipments <br />F-- ❑ Import to U.S. ❑ Export from U.S. Port of entrylext: <br />Z Transporter signature (for exports only): Date leaving U.S.: <br />W 17. Transporterftnowled ment of Receipt of Materials <br />onth <br />Transporter 1 Printe Name Signature MMMT Day „ Y <br />O <br />QTransporter rintedriyped Name Si ture Month Day 1 <br />LL <br />F <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type I^I Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />t� <br />Facilltv"s Phone: <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />2. 3" 4. <br />20. Designated Facility Owner or Operator: Cartificatton of receipt of hazardous materials covered by the manifest except as noted in ftem 18a <br />eT-.,.drn.—A Ki— Siqnature r <br />8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED F A.i .s'1.a"t"V TO DESTINATION STATE (at FtEQUIHED) <br />