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Please 'G n r,Tail a qof to-.p,T�C� Box 400,Sacramento.CA sss12-0400 with d s� <br /> p type. orm est ned,or eon eh a e -oito )typewmec) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1. ' erator Number / f 2.Page 1 of 3.Emergency Response Phone 4.Man'rfest Tracking Number <br /> WASTE MANIFEST = V� (G 1 14=424-493"M 0 0 2586990 JJ K <br /> 5.Cenermar's Name and Nailing Adore a - r•-' Generators Site Address(if different than mailing address) <br /> 4�4 <br /> Genemmrs PhonB:' .]��7> <br /> 6.Transporter 1 Company Name U.S.EPA 10 Number <br /> Evergreen Environmenta 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 /> GM Smith Ave. <br /> Newark, CA 345W <br /> Facility's Phone: _ C <br /> no, 91h.US.OOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(H any)) No Type Quantity Wl.NoL 13.Waste Codes <br /> e 404f' ;C/14W^1<-jti/ <br /> w ��gJ,ni!/�� l7' f i <br /> /L,G1a7c.c�� / <br /> ireN w.v�leJ iz� <br /> ®rG� tvr7u <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 5i3y- g/3 y- n <br /> 15. GENERATOR'SIOFFEROR'S CERTI KATION: hereby declare that the contents of this consign enf ora fully and accurately described above by the proper supping name,and are clossilled,packaged, <br /> marked and labeledlptacarded,and are in all respects in proper condition for transport according to applicable intemationaland national govemmentai 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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(d I am a small quantity generator)is true. <br /> Generatores/Ofiemrs Pdnted7/yped Name SignaWre Month Day Year <br /> 16.International Shipments <br /> i ❑Import to U.S. ❑Export from U.S. Part of entiylexit <br /> Transporter signature(for experts only): Dale leaving U.S.: <br /> w 17.Transporter AcknoWed nt of Receipt of Materials <br /> OTransporter 1 Pon Name Signature Month Day Year. <br /> N me <br /> Tmnsporte dnted?ypatl Name Si nature Month Day Year <br /> K <br /> r— <br /> 18.Discrepancy s <br /> 18a.Discrepancy Indicatlon Space ❑ Quantity ❑Type ❑Residue ❑Fall Rejection ❑Full Rejecbon <br /> Manifest Reference Number. <br /> 1St.Altemale Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> W Facility's Phone: <br /> w 18c.SignatureofNtemate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> N <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recyding systems) <br /> w 1' <br /> 2. 3. 4. <br /> D <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pirmac/fyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACiLiTY TO DESTINATION STATE(IF REQUIRED) <br />