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Seo 04 09 03: 10p Lindsay Schwager 2099523389 P. 11 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMR No.2050-0039 <br /> UNIFORM HAZARDOUS 1 erator ID um 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST ' 1 1-800-424-9300 002390296 JJ K <br /> 5.Generatoes Name and Mai' ,yy 2 Genemmes Site Address[f different than mailing address) <br /> Genaafo!a Phone: 3 <br /> 6.Transporter 1 Company Name U.S.EPA 10 Number <br /> Evergreen Environmental Services CAD982413262 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Evergreen Oil, Inc. <br /> 6880 Smith Ave. <br /> Newark,CA 94560 <br /> Facei(a Phone: 510-795-4400 CAD980887418 <br /> ga, So.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number. 10,Containers 11.Tota; 12.Unit, <br /> HM and Packing Group(if any)) No. Type Quantity NdN/.vol. 13 Waste Codes <br /> Olt kE <br /> le I M* <br /> z <br /> W I <br /> 3 <br /> _ I <br /> 4, <br /> 14.Special Handling Instructions and Additional Information <br /> zw—(?.-� 7hlS( ;�`� <br /> 15. GENERATOR'&OFFEROR'SCERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packagee, <br /> moved and labeledlplacarded,and are In all respects In proper condition for transport aaordkg to applicable Intam slanaland na0bnal governmental regulations.If export shipment and I am the Primary <br /> Exporter,I barely that the contents of this consignment conform to the terms of Ne attached EPAAcknmviedgment of Consent. <br /> I tartly that Ne wage minimization statement identified in 40 CFR 262.27(a)(e I am a large quantity generator)or(b)(If I em a small quantity generator)is true. <br /> Genera alOBerora Pentad d Name 5 re Month Day ver <br /> a9 <br /> F <br /> 16.international Shipments El Port to usS <br /> Ira Export from US. Po entry/exit: <br /> Transpartor signature(for exports only): Date leaving U.S.: <br /> W 17.TmnsporterAcknoO meet of Receipt of Melenels <br /> P'o Transported Printed if dName SignaWre Monty Day Veeg, <br /> a - <br /> QTrani 2,%ntedi Name Signi Monty Day Year <br /> C <br /> F <br /> 18.Discrepancy EI <br /> 18a.Discrepancy lndimt'm Space El Quantity ❑Type 1:1 Residue LlPamlal Rejectionj <br /> Full Re amen <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> rax. Facililys Phone: <br /> ace 18c.Signature of Atornale Faollty(or Generator) 61nrnh Gay Year <br /> 2 <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1 2, 3. 4. <br /> F <br /> signated Faciley Omer or Operator:Certification of receipt of hazardous materials covered by ere manifest except as torted in Item 18a <br /> rTvped Neme signature Morm Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED', <br />