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State of California—Environmental Protection Agency <br /> Form App/oved OMB No.2050-0039(Expires 9.30-99) See Instructions on back ofb. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(12-pitch)*-r-c_u_r Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> k-FUNIFORM HAZARDOUS , k is not required by Federal law. <br /> WASTE MANIFEST {_ t`` �j ' .. of <br /> 3. Generator's Name and MailingAddress �! A. State Manifest Document Number <br /> 122964412 <br /> �I t B. State Generator's ID <br /> LO <br /> LO <br /> �- / <br /> 4. Generator's Phone ( ) �? �To x <br /> N S. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> to <br /> tb :A Ea TY-K L E E Id S Y S T E `,_i PIC m X 1 0 f F 0 0 c"0 q.:l 0 D. Transporter's Phone <br /> o 800 669-5840 <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> F. Transporter's Phone <br /> V 9. Designated Facility Name and Site Address h 10. US EPA ID Number G. State facility's ID <br /> L}J�1.1:>a GA "f 4 $ <br /> ! Z EVERGREEN OIL INC <br /> li8 8 0 SMITH AVE CAD 9 8 0 8 8 7 4 1-8 H. Facility's Phone <br /> �O NEWARK CA 94560 1 1 1 1 1 1 1 1 1 1 1 510 795-4400 <br /> 12. Containers 13. Total 14. Unit <br /> V11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol I. Waste Number <br /> = a State <br /> NON—RCR.A. HAZARDOUS WASTE LIQUID <br /> G OIL, WATER, SLUDGE( NOT LOOT RL`GULAT D f U CS f ]/ 1 EPA/Other <br /> E <br /> State <br /> o NOD <br /> b. <br /> W E EPA/Other <br /> v R <br /> N <br /> v A c State <br /> o T <br /> a8o O EPA/Other <br /> R <br /> LU d. <br /> State <br /> Z EPA/Other <br /> V <br /> rn J. Additional Descriptions For Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> O j b. <br /> W <br /> c. d. <br /> J <br /> Q <br /> Z 15. Special Handling Instructions and Additional Information <br /> 0 M ST R/T OOOO00000 0-000-00 <br /> P HMEPGENCY RESP 800-458-- 1760( 24 HR ) . IF UNDELIVERABLE RETURN TO GEI"iR.ATOR . <br /> Z SK CORP AUTHORIZED TO RETAIL' LICE14SED SUBSEQUENT CARRIERS AS NECESSARY. <br /> LU <br /> F- SKDOTI A 3287 Fi t <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 /> Vmarked,and labeled,and are in all respects in proper condition For transport by highway according to applicable international and national government regulations. <br /> -J+ If I am a large quantity 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 health <br /> N 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 /> available to me and that I can afford. <br /> Ori ed/Tyeed Name Signatur ! Month Day Year <br /> UjLU T 17. Transporter 1 Acknowl d ement of Receipt of Materials <br /> R I <br /> Uj 1 Month ay Year <br /> A Printed/Typed Name C/.., Signature <br /> Is <br /> U- 0 18. Transporter 2 Acknowled ement of Recei t of Materials <br /> 0 R Signature Month Day Year <br /> LU E <br /> T "d/Typed Name 9 t <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> I 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T <br /> Printed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> Blue: GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br /> DTSC 8022A(1/99) To: P.O. Box 400, Sacramento, CA 95812-0400 <br /> EPA 8700-22 <br />