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State of California ~Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) See Instructions on back of e b. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(12-pitch) ter. Sacramento,California <br /> r n <br /> 1.'Generot6''s US AID No. Manifest Document No. 2, Page 1 Information in the shaded areas <br /> 'UNIFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFEST { `� " /` < ofl <br /> 3. Generator's Name and Mailing Address 11 q A. State Manifest Document Number <br /> O L °; f 1 B. Slate Generator's ID 22964412 <br /> y f. t <br /> LO A. Generator's Phone <br /> f\ <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.) <br /> W) <br /> 00 <br /> Ai, T Y_.KT L E E N SYSTEMS INC 1;T .. CCC) Q .li D. Transporter's Phone <br /> O6(-'�9-5840 <br /> 00 7. Transporter 2 Company Name B. US EPA ID Number E. State Transporter's ID[Reserved.) <br /> f� <br /> F. Transporter's Phone <br /> .Q <br /> ®U 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> 09-01702 q ?9111111f7fl8l <br /> 1Z EVERGREEN OIL INC H. Facility's Phone6880 SMITH AVE CPD980887418 <br /> - <br /> 1� NEWARK CA 94560 10 `�95- 4400 <br /> Q 12. Containers 13. Total 14. Unit <br /> V 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) Type Quantify Wt/Vol I. Waste Number <br /> No. <br /> = a NO14-RCRA HAZARDOUS WASTE LIQUID State 212121-1 <br /> CIL, ATER, SLiJDGE( NOT DOT REGULATED) TT EPA/Other <br /> O N b' State <br /> 00 <br /> 00 E <br /> v R EPA/Other <br /> qA C. State <br /> 6 T <br /> O0 0 EPA/Other <br /> R <br /> LU d. <br /> State <br /> Z <br /> LU <br /> V EPA/Other <br /> w <br /> V) J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes listed Above <br /> Z <br /> O °' l b' <br /> V) <br /> w <br /> ce C. d, <br /> J <br /> Q <br /> Z 15. Special Handling Instructions and Additional Information <br /> O MFST R/` #000(}00000 0--000-00 <br /> Z ERC�ENCY RESP 8OU-X466-1760( 24 HR ) . T.I` UNDELIVERABLE RETURNTO GENERATOR. <br /> C ORP AUTHORIZED TO RETAIN LICESED S'UBSEQ �E CARRIERS AS NECESSARY, <br /> W <br /> t— S 1 ' s 2 <br /> 16. GENERATOR's CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed, <br /> Q marked,and labeled,and are in all respects in proper condition For transport by highway according to applicable international and national government regulations. <br /> V <br /> IF I am a large quantify generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human healt <br /> V) h <br /> and the environment;OR,if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> ce available to me and that I can afford. <br /> O <br /> Pri ted/Typed Name Signature✓" Month Day Year <br /> V ( i <br /> Z <br /> 'L T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> w <br /> A Printed/Typed Name Signature Month ay Year <br /> w»-." 1 / <br /> UJI <br /> P -' <br /> rL 0 1 B. Transporter 2 Acknowledgement of Receipt of Materialsf <br /> 0 T Printed/Typed Name Signature , Month Day Year <br /> LU E <br /> N R «' <br /> () 19 Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> L <br /> I 1 20. FacilityOwner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> v <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A(1/99) Yellow: GENERATOR RETAINS <br /> EPA 8700-22 <br />