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Hearse print or type.(Form designed for use on elite(12-pitch)typewnler.) Form Approved.OMB No.2050-003' ve nerator ID Number 2 Page 1 of 3 Emergency Response P 4.Manifest Tracking UNIFORM HAZARDOUS � g Number WASTE MANIFEST 9L h-�7�n 1 1-800424930b- 006660715 JJ K 5.Generator's Name and Mailing Address�GlT/V�/ � J Generators Site Address(if different than mailing address) Generators Phone: 8 Transporter I Company Name US EPA ID Number Evergreen Environmental Services CAD982413262 7 Transporter 2 Company Name U.S.EPA ID Number d Desugnated Facility Name and Site Address U.S.EPA ID Number Evergreen Oil, Inc. 6880 Smith Ave. Newark, Ca.94560 CAD980887418 Facility's Phone. 510-795-4400 ga 9b US DOT Descnptan(including Proper Shipp ng Name.Hazard Class,ID Number, 10 Coria+Hers 11 Total 12 Unit HM and Packing Group(d any)) No Type Quantity Wt No1 13.Waste Codes x ULJ i Z'' X fid,/Li1 14 5 _ Narw r 9 Ins ucticns and Aad i drt I tormau / i�/f7�oV,t/�'a/�r�/�/D, d//� 96 a 5-�-- 71 5 7 _t5 GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this mrisignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeledlptacarded,and are in all respects in proper condition for transportaccording to applicable mtematronal and national governmental regulations If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity r)or(b)(if it quantity ge rator)is true. Gene2tors Offerors PnntedlTyped Name tui. t D rr �S r t =.r 16 internabotial Shipments I'– mport to U.S tJ Export from U S Port of ert exit: Z Transporter signature(for ex oN — -- P� y) Date leaving U.S.. a 77 Transporter Acimow ledgment of Receipt of Materials LLJ Transporter t Pr Hied lyyped Na Signature Month Day Year zLAJ1emat*@ Printed/Typed Name $mature Month Day Year indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejecuen 6ty;or Generator) Manifest Reference Number. J U.S EPA ID Number U I Faclrtys Phone: w 18c.Signature of ARemate Facility(or Generator) Monti Day Year Q Z wC) 19.Hazardous Waste Report Management Method Codes It e.codes for hazardous waste treatment, I, systems disposa and recycling ) 0 1 2 3 4 20.Des gmaled Facility Owner or Operator Certification of receipt of hazardous matenats covered by the manifest except as noted in Item 18a PnmedrTyped Name Signature Month Day Year EPA Form 8700.22(Rev.3-051 Previous editions are obsolete DESIGNATED FACILITY TO DESTINATION STATE (1F REQUIRED)