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'•Generator,mail a copy to:OTSCBox 400,Saerameri CA 958124MM ridgy days <br /> Please print or type.(Form designed for use on elite(12-pitch typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.qqnemtor ID Number 2.Page 1 <br /> 1 3.Emergency Response Phone 4.Manifest Traddng Number <br /> WASTE MANIFEST Jy`�`f� 1. 1-soo424-ww 002586980 JJ K <br /> S.Generators Name and Mailing Adtlre „�A_,A^ V� 0/,G,6 � Generators Site Address(if different than mailing address) <br /> Gederatws Phorfe: i X327 J <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Evergreen Envirommer" Services - CA119=1311;1, <br /> 7.Transporter 2Company Name U.S.EPA ID Number <br /> 8.Designated Faulk Name and Site Addrei U.S.EPA ID Number <br /> Evergreen Oil,,Inc. <br /> OW Stnith-Ave. <br /> Nftr^,'CX 9 0: <br /> FaciliFJs Phone: 510]'W_j' } <br /> ge, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, - 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if ani No. <br /> Type Quantity WLNol. 13.Waste Codes <br /> o Wit 'N7Ji�d/�1�6 03 <br /> �o <br /> 1- 3iUNf�31 loo <br /> W I 2! <br /> Z 2. N �F/ 7e�1eG/Z3 <br /> 4. <br /> 74.Spedal Handling/Con 1s ditional lnformafian <br /> P.��/` p2lZ/7 b <br /> 15. GENERATORBIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,aid are classified,packaged, <br /> marked and Iabelecliamcarded,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 EPAAcknowledgmeid of Consent <br /> I certify that the waste minimb ation statement identified in 40 CFR 262.27(a)(N I am a large quantity,generator(or(b)(if I am a small quantity generator)is true. <br /> Generramiess//O�Uemrs Printedfryped Name,/ Signature Month Day Year <br /> / ""!� ✓1.X37 `� y r te. 23 Oj <br /> 16.International Shipments <br /> r— El import to U.S ❑Export from U.S. Pad afentry/edt: <br /> = Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TransporterA edgmem M Receipt of Materials <br /> a Transporters Eryped Name � Slgnaw �/ Month Day Year <br /> $/ >' <br /> Tran rter2 Print NameSigni ManM Day Year <br /> K <br /> ♦ 18.Discrepancy <br /> 18a.Discrepancy Indication SpacaQuantity Type l El Full Rejection <br /> ❑ ❑Residue ❑Portal Re ection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Gerreramr) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facility's Phone. <br /> Q <br /> 16o,Signature of Alternate Faulk(or Generator) Month Day Year <br /> z <br /> z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> m 1 2. 3. 4, <br /> 0 <br /> 20.Designated Facility Owner or Operator:Cerdea sin of receipt of hazardous materials covered by the manifest except as noted in Item 1 B <br /> PrintediTyped Name Signamm Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />