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Please print or type.(Form designed for use on elite(12-pitch-)�rpevvriter.) • Form Approved.OI, <br /> UNIFORM HAZARDOUS 1.Ge rotor Number ' / 2.Paggency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST O! IO g /.� e 1 of3.Emer1 1-800-424-9300 002390392 j, <br /> 5.Generators Name and Mailing Add k„/ 7 AM Generators Site Address(if different than mailing address) <br /> Am to hone�ea: " /� L% �1 7-- <br /> 6. <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 /> Facil 's Phone: 510-795-4400 CAD980887418 <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if anyt) No. Type Quantity WtJVW. <br /> �M <br /> P!G <br /> w i <br /> z z. <br /> w <br /> 3. f <br /> I <br /> 4. <br /> 14.5 ed an gInsWctions andAdditianal Information <br /> 15. GENERATOR['-SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and a=mtely described above by the proper shipping name,and am classified,packaged, <br /> marked and labeletllplacarded,and are in all respects in proper condition far 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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(6)(if I am a large quantity generator)or(b)(fl am a small quantity eneratm)is tue. <br /> Generato'slOffemes Prinledrryped Name Signature Month Day Year <br /> IPJ LgPeZ ($ p J <br /> J 16.International Shipments <br /> F ❑Import to U.S. ❑Export from U.S. ort of entry/exit <br /> ? Transporter signature(for exports only): Date leaving U.S: <br /> w17.Transporter AclmoW ment of Receipt of Materials <br /> oTransporter 1 Printe Na� Signature Monty pay Yg <br /> d /h <br /> C Transporter PdntedlTypetl Name <br /> SignWfm Month Day Year <br /> a <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residua ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 186.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> ra+- Fadlitl+s Phone: <br /> F18c.Signature of Alternate Facility(or Generator) Monro Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> w <br /> 1' 2. <br /> 20.Designated Facility Omer or Operator.Certfication of receipt of hazardous materials covered by the manifest except as noted in Item IBe <br /> Il Pdnted?yped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions am obsolete. - <br />