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11OV-15-2004 14!0I-3REEI-1 CAL 111C 606 0133 P.03 <br /> lean print or type, form designed for vie CPR alis.(12-pits JFer. v - <br /> Sacramento,Cofil6mic; <br /> UNIFORM HAZARDOUS jdAIWOldt"t US EPA ID No. MOFliF&il DO.A. - 2, Page I Information in lhe shaded�br#q' <br /> WASTE MANIFEST it not required 6y Federal In. <br /> 3, Goinerolof'o,Name Ord Mailing Address <br /> 7�wj"7'e <br /> : :- 22673083 <br /> //,7 1) J I 97��Krllkl 7—ow 64 <br /> LO 111 Goner-allor';ID <br /> UNIFORM <br /> a. Generator's Phone <br /> WASTE <br /> (�qi gy <br /> _y <br /> S. Tmn.pa I.,I C-mprony Name 6. US EPA 115 Number <br /> Ln <br /> EVERGREEN ENVIRONMENTAL SERVICES <br /> D <br /> 284. <br /> _]A_J <br /> 8 P P <br /> 7. Transporter 2 Company Nome a, US EPA t!)Numbor E. StatR TrgtllfWrfer FD <br /> F. YrrNteptir�r <br /> 9. Designated Fiatility N...and Sites Addirtass W. US EPA ID Number IS 3]ltrie, <br /> EVERGREEN OIL, INC, it <br /> 080 Smith Avenue H. F111cillife, <br /> r7 y 7914 <br /> 400 <br /> Newark,CA WOO A.A 19 is 10 18 A V 1 0 (0 B <br /> 11. US DOT D.mriplialt lincluding Proper Skipping Nome,Hoard Cl—,and ID Numli.rl Canfainers 13. Total 14. Unit <br /> No. 7 do 4uanti WI/Vol I, walis,WWI <br /> z <br /> G hON-RCRA HAZAR OUS WASTE, LIQUID <br /> 0 P L�T <br /> E <br /> N b' 5retr <br /> R <br /> A C <br /> t <br /> 0 <br /> jz <br /> �VO"W <br /> Main <br /> U <br /> to <br /> in I- AdStiORni D*Kfipil'an-Far Mlafilrri011.Listed Aluive K. cadow fir"Witsioto, <br /> z " Ustsid.Abi-ve. <br /> V) <br /> U.1 <br /> G. <br /> 15. Special Handling Instructions and A.Milicinal l6faematiaA <br /> 24 Hour Emergency Response Telephone No.-CHEMTREC 1-800-424-9300 invoice I <br /> z DOT ERG 171 WEAR PROTEC'nVE EQUIPMENT sales Order 576, �5-171dr-6 <br /> 16- GIEWRATOR'S CIERTIF"7110N, I hereby declare that the contents of this consignmtril are fully and—uroielio,daw;b*d a"by proper shipping name and are classified,packed, <br /> morwl and label",and are in all reiFiecis m proper czandition fur trampatt by highway according To applicable inkroolional and r ofienal ga.rvnmenl regulation*. <br /> If I am a largo quonriry generator,I colify 161 1 40're 0 p10 place to reduce the volume and toxicity of wo3t;goo-onvlood to the degree I have determined to be oconom;call <br /> 'ayrUM in P CC <br /> rocl;C061 t treatment,Oorcoge,or disposal currently a.Ailalollii la ma which minimises rho preterit and Future litroot to human hoolz <br /> prom-limblit and that s a"Infected the a me <br /> and 16 OR,if I am 0 small quantity generator,I have made a good fain,Atarf b minimize my w00%gtoneragari and select the boil vicitto management matkad that it <br /> taNvailo6l to me and Thai I can afford.0 <br /> Prints 4jT,&0&d NC INA Signalan Month Day <br /> z <br /> 01 421� (9111 C,12 <br /> us R T 17. Trans er 1 Aeltnowled emanl of ReceiEl&F Mo4oriols <br /> be <br /> it Frintioul/Irypiod No— Month Day Y�r <br /> P <br /> IF, tn)V- <br /> LU J61 A <br /> a Ia. T--partor 2 AcUncpledfiamon)of Receipt of Motbrials. <br /> R <br /> 0 T Day year <br /> Signature Month <br /> w <br /> U 19 Discrepancy Indicalion Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> 1 70, Facile Owner a,Ovarniar Cwtificotior of mc*;o?of hazoed--malitriolt covered/4 Wt manifest oxcapi or no - item 4. <br /> I Priwo^.d Nome Signall—X'117 h Day e-j�q <br /> Y I I I <br /> 31 4,- <br /> DO NO RITE BELO )H I S'LINE. <br /> White; TSE)F SENM THIS COPY TO DTSC WITHIN 30 DAYS. <br /> EPA 8713 <br /> DISC 9022A I I/99) To: P.0. BoA 3000, Sorrrimen!b. CA 95812 <br /> 0-22 <br />