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Please print or type.(Form designed for use on elite 12-pitch)typewriter.) Form Approved.OMB No.2050-0039 2 Pae 1 of 3.Emergency Response Phone 4.Manifest Tracking Number �-?) Numb-r g UNIFORM HAZARDOUSiG, 1 1-800-424-9300 6 JJ WASTE MANIFEST Generator's Site Address(if different than mailing address) 5.Generator's Name and Mailing Addres G��3`f nerator's Phone: U.S.EPA ID Number 6 Transporter 1 Company Name CAD982413262 Evergreen Environmental Services U.S.EPA ID Number 7 Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address Evergreen Oil,Inc. 6880 Smith Ave. CAD980887418 Newark, Ca.94560 Facility's Phone: 510-795-4400 10.Containers 11.Total 12.Unit 13.Waste Codes 9a 9b.U.S.DOT Description(including Proper hipping Name,Hazard Class,ID Number, e Quantity Wt Nol. HM and Packing Group(if any)) No. Type Vial . O LU - 14.Special Handling Instructions and Additional In Drmation j- 9G. 3 q,6 3 -/7/ 715. GEN—ERATOR'SiOFFEROR'S CERTIFICATI N: I hereby declare that the contents of this consignment are fully and accurately descr bed above by the proper shipping name,and are classified,packaged. ed and labeledlplacarded,and are in all respects in proper conditionfor transport according to applicable international and national governmental regulations.If export shipment and I am the Primary rter,I certify that the contents of this co signment conform to the terms of the attached EPA Acknowledgment of Consent. ify that the waste minimization staterner t identified in 40 CFR 262.27(a)(if I am a large quantity generator)orb (if I am a small quantity generator)is true. Month D�i Year Generalor'sl0fferor's Pdnted/Typed nName Signature LIQ [5 � J 16.International Shipments El Import to U.S. ❑Export from.l3:S. ort of entry/exit: ---— F- Date leaving U.S.: z Transporter signature(for exports only): W 17.Transporter Acknowledgment of Receipt of Ma erials Month Day Year Transporter 1 PrintedlTyped Name S/ ) `/ O �'� -- CL i Month Day Year QTransport 2 Pdnted(Typed Name Signature t- 18 Discrepancy 18a.Discrepancy Indication Space El Q entity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: U.S.EPA ID Number 18b.Alternate Facility(or Generator) J U LL- Facility's Phone. Month Day Year O 18c.Signature of Alternate Facility(or Generato) S Q Z S2 19.Hazardous Waste Report Management Met iod Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) w 1 2. 3. 4. O 20 Designated Facility Owner or Operator Ce tification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Month Day Year PrintedfTyped Name Signature EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)