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J� + 1 GMerators US EPA ID NO <br /> NO2 oP'Page 1 3 taocument Number <br /> O - NH- N2 3796 <br /> 4 Generators Name and Mair Address }`,14►n� Core <br /> Y <br /> Generator's Phone r ! <br /> 5 Transporter Company Name 6 US EPA ID Number 7 Transporter Phone , <br /> EVERGREEN ENVIRONMENTAL SERVICES ! 510-795-4401 <br /> CAD982413262 <br /> r ° <br /> �J 8 Designated Facility Name and She Address 9 US EPA ID Number 10 Facility's Phone <br /> L <br /> I <br /> Evergreen Oil, Inc ; <br /> 6880 Smith Avenue <br /> G Newark CA 94560 CAD980887418 510-795-4401 - <br /> E 11 Waste Aping Name and Description 12 Containers 13 Unit <br /> 14 <br /> N I No T Ouanul wwol <br /> E <br /> R a <br /> T Non-Hazardous waste, liquid �} <br /> T 001 TT G <br /> 0 Water and oil <br /> b a k <br /> r Handling Codes for Wastes Listed Above t <br /> 15 Spedal Handling Instrudtions and Additional tnfonnahon S , <br /> 11a Fy 11b <br /> Do not ingest <br /> Wear protective clothing <br /> In case of emergency-510-795-4401 <br /> DOT ERG 31 <br /> PQOMAN <br /> _18 QENERA I peQ�pyrontft'ttelfifsfttlrithlt itOtitRtROrI�Otii f r <br /> Printed/Typed Name Signature 5 7 r— T` <br /> f <br /> Month Fay F Year <br /> S .: 041 <br /> P. <br /> O Printodnyped Narne Signature <br /> -, <br /> R 1 <br /> Month bey", Yofr <br /> T 1 <br /> R <br /> 18 biauepattcy indreatbn Spam <br /> F <br /> 3 <br /> C <br /> L <br /> i - <br /> printedlTyped Name � taro <br /> �...�Mn�fhD-y�YZ <br /> NSPORTER COPY GOLDENROD—GENERATOR'S COPY <br /> WHITE—ORIGINAL(Return to Generator) YELLOW—TSDF(Retain Copy) PINK—TRA <br />