Laserfiche WebLink
**Generator,Mail a copy to. DTSC p.0.Box 400 Sacramento,Ca.95812-4400 within 30 days.* <br /> Form Approved.OMB No.20511-0038 <br /> Please print or type.(Form des nail for use on e{ite(12 p tch)t ter•} 2.Pago 1 of 3.Emergency Re <br /> sponsePronedfost Trocklr�Numbur <br /> UNIFORM HAZARDOUS �Num��� L� JJ K <br /> WASTE MANIFEST ` "'s + y .aloes Sk Address(it ddforent than maillma'dddrreersO <br /> 5.Generalo's Mara and t tg Address <br /> Gator's Phoros: � f U.S.EPA 1)Number <br /> 8.Transportar'�Company Marrs CAp98241326Z <br /> r en Environmental Services U.S.EPA 11)Number <br /> 7.Transporter 2 Company Nacos <br /> U.S.EPA ID Mur-ber <br /> 8.m*natad Fadlity Name and Site Address <br /> Evergreen Oil,Inc. CAD980887418 <br /> 6580 Smith Ave. <br /> Newark,Ca.9456D <br /> Facility's Plane: <br /> 10.Containers it.Total 12.Unit 13.Waste Codes <br /> 90. 9b.U.S.DOT I)ascrip5on(nci drug Proper Sh!ppvg Nemo,MmaM Crew,m Number, Quantity 11LNd. <br /> HM and Padarxg Group(deny)) <br /> LLJ <br /> No. Type <br /> 3. <br /> 4. <br /> r <br /> 14.Speaidd ta3rrafcmaEn z„pyu-Ioe— <br /> 15. GEMERATOR'sfOFFEROKS CERTIFICATION:I hereby deda a that the conbar s of 114s oo,.*gnment are tu➢y Ord acaratet descrtoed above by the proper ahlpping na'nhe,and are daWoed,and I am the packaged, <br /> you <br /> rexvicod and Labe eapiaeardod,and are In al respects in proper conditkm fir Uanepert according to applicable t nationai and no�a-ml govemmenta regutaticos- xrAR O <br /> Expor:er,I certify,that the contents of this consignment conform V Dia V. ms of the aliad*d E.PAAdmwladgmert cf Comm <br /> t ce tty tt..at dna waste rntrimdzaWn saatement Identified In 40 CFR 282.27(x)(1 I en a large qusntty ganarator)or(b)(I I am a smell qt: y gersrator)is.rue. <br /> re tiorrtlt Day �etx <br /> Ganerato<si0ffarcr's?rkntedt?ypad�� <br /> 1S.i ltenait Wlal Shipnr0nis _! frem U.S. Port,of xit <br /> ❑Import:c U.S. <br /> Transporier signature(for exports only): Date Ie U.S.: <br /> i <br /> i W 17.Tr&)spcMAcloxmkrcgment of Recapt of Matedats Month Day Year <br /> i 0 TranapoAer 1 Pdnte+UFypad Nama <br /> CL i� $ <br /> Z Transpoder 2 Pnntad(Typed Name <br /> Signatr Month Day Year <br /> 18.Otscyeparna/ r—I <br /> 183.�y ImIcatiat Space ❑awr".ty i�Type ❑Ras dry lJ f aMa Rejadian ❑Full Reiac!bn <br /> U <br /> Mandest Reference NvtrrYJeC <br /> 18x.Mlemato Facility(or Genar U4 U.5.FPA 10 DM,ruber <br /> i <br /> U <br /> 4i.. Faclil ys Phone: ,_ , Year <br /> 18x.Signature of Alternate Facility(or Garurabr) <br /> 19.Huzardous Waste Report Mmagemant Ne hod Codes S e.,tx s'a hazard nrg waste irea6 tent,dtspas0l,and recycling Systeme) <br /> p' <br /> 135 <br /> 20.Designated Fadity Owner a Opembr.Certif4stien of receipt of hazardous materfaN ouvated ty`he mardfesi except as noted in m 18s <br /> t ad <br /> We ora ono; Day Yaw <br /> ! !I 2221 I <br /> HATED FRGILrfY T <br /> ePA Form 8700.22(Rev.MS) Previous a ons are obsolota. O DESTINATION S*IATE(IF REQUIRED) <br />