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*�Uffil <br /> < �'` 41 Generators U5 EPA IQ Na2 Page 13 Document Number <br /> y; m �t NH-- �� 1744 <br /> 4 Generators Name and Mailing Address �£ ��[ EES 19 <br /> 1 X 76 �'OON7ix'l et ag <br /> " Gene°orale'"3G' ✓%oir t l �� e!q quo 4 <br /> 5 Transporter Company Name 6 US EPA!D Number 7 Transporter Phone <br /> EVERGREEN ENVIRONMENTAL SERVICES <br /> CAD982413262 800-972-5284 <br /> 8 Designated Facility Name and Site Address 9 US EPA ID Number 10 Facility's Phone <br /> Evergreen Oil, Inc <br /> 6880 Smith Avenue <br /> G Newark, CA 94560 CAD980887418 510-795-4401 <br /> E 11 Waste Shipping Name and Description 12 Containers 13 14 <br /> N Total Unit <br /> E No Type Quantity WVVol <br /> a a <br /> T Non-hazardous waste, liquid // <br /> 0 Water and oil 001 TT L� G <br /> b <br /> 15 Special Handling Instructions and Additional Information Handling Codes for Wastes Listed Above <br /> 11a 11b <br /> Profile# <br /> Do not Ingest <br /> Wear protective clothing Invoice 77a �F ~, <br /> In case of emergency call CHEMTREC 800-424-9300 Sales Order � �Z ��� <br /> DOT ERG 171 <br /> 18 GENERATOR'S CERTIFICATION. I certify the materials described above on#tk muftst are nasubject to state orfadere!reguiationsfor reporting proper disposal of Hazardous!Netto <br /> Printed/Typed Name Signature <br /> T / f <br /> R ^ !J�` �rt� l4 js 'r �.1 r rT r Month Year <br /> A r -�-t . . i o 71731 <br /> N <br /> S 17 AedrnovdedgeMnt of Receipt of Mtaterla4s <br /> CPnnted/Typed Name Signature f r <br /> T '� / r <br /> Ate( � j' - � 07 <br /> 13r <br /> 18 Discrepancy Indication Space f` <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1=at�t Owner or Operator t",elcb5r�tiorl of receipt of waste rtsaterials oovp4ed 'ttrlsii>ar�ezcePt es noted tri ttAns 18 ,`, `` <br /> Printedilyped Name Signature . <br /> month Day Year <br /> WHITE—ORIGINAL(Return to Generator) YELLOW—TSDF(Retain Copy) PINK—TRANSPORTER COPY GOLDENROD—GENERATOR'S COPY <br />