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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Ge ralor ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 6wooO /�m��K 1 1-800-424-9300 002390446 JJ K <br /> 5.Generator's Name and Mailing Addri <br /> Generators Site Address('rf different than mailing address) <br /> -> -ji�8 <br /> Ge erators Phone: <br /> 6.Transporter 1 Company Name - U.S.EPA ID Number <br /> Evergreen Environmental 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 /> 6880 Smith Ave. <br /> Newark,CA 94560 <br /> Fadlitys Phone: 510-795-4400 CAD980887418 <br /> 9s. 91b.U.S.DOT Desuiption(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Pecking Group(rf any)) 13.Waste Codes <br /> No. Type Quantity WLNd. <br /> 1 r91r:1/C�kf6 � '4-S f� al -4 <br /> w / � <br /> z 2. <br /> W <br /> 3. <br /> 4. <br /> j <br /> t <br /> 14.Special Han in InstructionsandAddltionallnfonnztion <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,ard are classified,packaged, <br /> marked and labeledlplamnled,and min all respects in proper condition for transport according to applicable irdemationaland national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment confemr to the terms of the attached EPAAcknmvledgment of Consent. <br /> I certify Nat the waste minimization statement identified in 40 CFR 26227(a)(d I am a large quantity generator)or(b)(ffI am a small quantity generator)is true. <br /> Genemtorsl08emrs PdntetlRyped Name Signature Month Day Year <br /> e Z 0 O <br /> —r 16.International Shipments ❑ <br /> F Importto U.S. L1 Export from U.S. o of entry/rxit: <br /> Transporter signaWre(for exporls only): Date leaving U.S.: <br /> w 17.Transporter Acknowiedgm t of Receipt of Materials <br /> hC Transporter l Pnntedfrarae Signature Month Day Year <br /> NI/ Mel <br /> a <br /> Za Iminsporter3,Fnifted/Typed Name Zignature Month Day Year <br /> K <br /> I18.Discrepancy18a.Discrepancy Indication Space ElQuantity ❑Type Residue Partial Rejection Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w 18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes lice.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3. 4. <br /> 20.Designated Facility Omer or Operator:CerOfigtio0 of receipt a:hazaNCW ma<,ia:;w.err.,1 ty mma�liin�e[�epi esixiui"m iie�n ioe <br /> PrintedRyped Name Signature Month Day Year <br />