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Please orint or tvoe. (Form desioned for use on elite 02-pltd, ,titer.) JA A `� `-" 7 ( <br />971 /C) Form Approved, OMB No. 2050.0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS 1. Gan rotor ID Number <br />��79 f <br />2. Page 1 of <br />1 <br />3. Emergency Response Phone <br />1-800-424-9300 <br />14. Manifest Tracking Number <br />0 0 3 3 003336101 JJ K <br />WASTE MANIFEST <br />5. Generators Name and Mailing Address..�x'✓tj° l�'� ! Generator's Site Address (if different than mailing address) <br />X <br />Genere <br />S. Transpo U.S. EPA ID Number <br />3iRY& atnvironnnental Services CAD982413262 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />B. Designated Facility Name and Site AddresuEverg reen oil, Inc. U.S. EPA ID Number <br />6880 Smith Ave. <br />Newark, CA 94560 CAD98O887418 <br />Faclli 's Phone: 510-795-4400 <br />ga <br />9b. U.S. DOT Descriptor (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />it. Total <br />12. Unit <br />13. Waste Codas <br />N,,,o.. <br />Type <br />HM <br />and Packing Group(t am/)) <br />Quantity <br />WWaI. <br />J.Nj <br />62 <br />/,�vI <br />Z <br />W <br />2. <br />F- <br />3. <br />4. <br />14. Special Handing, sWctions and Additional information <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, and are classified, packaged, <br />marked and labeledlplacarded, and are in all respects In proper condition for transport according to applicable international and national governmental regulabDns. If export shipment and I am the Primary <br />Exporter, I cenly that the contents of this consignment conform to the terms of the attached EPAAcknowledgmenl of Consent. <br />I cenly that the waste minimization statement identified In 40 CFR 262.27(x) (if I am a large quantity generator) or (b) (if I am a small quentay genera r) is We. <br />GeneratorsrOfferors Printedlryped Name Signature Manch Day Year <br />1t-lDc41—�- C4>Jk=—'�- -�!7 1 IV <br />—r <br />i— <br />16. International Shipments <br />❑ Importto U.B. ❑ Export from U.S. Port of an xB; <br />z <br />Transporter signature (for exports only): Date le ing LLS.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />C <br />Transporteri Print , /p�ed�Neme Signatu-7110 re Month Day Year <br />Transportaf 2 Pdntedrryped Name Si re Month Day Year <br />K <br />H <br />} <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ TyPe ❑ Residue ❑ Perlial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />Ithe Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />V <br />LL <br />Factlity+s Phone. <br />W <br />180. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />G <br />z <br />y19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />1, <br />2. <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a <br />1 <br />PrintecifTyped Name Signature Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />