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**Generator,Mail a copy to: DTSC P.O.Box 400 Sacramento,Ca.95812-0400 within 30 days.* Please print or type.(Farm designed for use one I ite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone4.Manifest Tracking Number ! WASTE MANIFEST C- 1��/ c5�ul' +� � 1 800-424-9300 008643883 JJ K K Generators Name and Mailing Address /,//c5v ;yy e-p, ' Goneralor's Site Address(!f different than mailing address) Generator's Phone: U.S.EPA ID Number 6.Transporter 1 Company Nae m Evergreen Environmental Services CAD982413262 7.Transporter 2 Company Name U.S.EPA ID Number 8:Designated Facility Name and Site Address U.S.EPA ID Number Evergreen Oil,Inc. CAD980887418 6880 Smith Ave. Newark,Ca.94560 Facility's Phone: 510-795-4400 ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Weste Codes HM and Packing Group(if any)) No. Type Quantity Wt.A/01. Z 2. UAe .. 3. 14.Special Handling lnstiuct'ons and Additional Information I S. GENERATOR'SiOFFEROWS CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classi`ied,packaged, 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 Exporter,l certify that the contents of this consignment conform to'he terms of'he attached EPAAckoowledgment of Consent. I certify,that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a largo quantity generator)or(b)(if Iam a small quaniEy go era tor)Is[rue. Go.norator's10ifero's PrinledlTyped Name Sionature Month Day Year 4 2� -A 16.International Shipmentsora tof tryl ❑Import to U.S. Expo U.S. Po z Transporter signature(for exports only): Date leaving U.S.: W 17.TransporterAcknowledgment of Receipt of Materials Transporter 1 PrintedlTyped Name Signature / Month Day Year O 145, cede � � � Month Day Year Transporter 2 Printad/Typed Name Signature 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Pa tial Rejection ❑Full Rejection Manifest Reference Number: 18b,Alternate Facility(or Generator) U.S.EPA ID Number J V LL Facility's Phone: 0Monfh Day Year 18c.Signature ofAl[erna[eFacility(or Generator) Z S219.Hazardous Waste Roport Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) UJ 1 (� 3. 4. NN( 2. f 20.Designated Facility Owner or operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printodrfyped Name Signatur Monfh r y Year EPA Form 8700-22(Rev.3-05) Previous editoAs are obsolete. ATED FACILITY TO DESTINATION STME(IF REQUIRED)