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c- t +a r <br /> ' 1 Generatods US EPA tD No 2 page 1 3 Document Number <br /> a <br /> of 1 NH— M! _ '1743 , <br /> ` Generators Name and Mailing Address ftc wrtoit,16, <br /> EES 19 _ _ <br /> I � i I S • Fr F,PC HrAf44P77'tII APIkA- <br /> Generator's Phone 10 1/t i 0A I ell `V5 06 <br /> I5 Transporter Company Name 6 US EPA lD Number 7 Transporter Phone <br /> EVERGREEN ENVIRONMENTAL SERVICES <br /> CAD982413262 800-972-5284 <br /> e Designated Facility Name and Site Address 9 US EPA tD Number 10 FacAly's Phone <br /> Evergreen Oil, Inc <br /> 6880 Smith Avenue <br /> G Newark, CA 94560 CAD980887416 510-795-4401 <br /> E 11 Waste Shipping Name and Description 12 Containers 13 14 <br /> N Total Unit <br /> E No I Type Quantity wWol <br /> R a <br /> T Non-Hazardous waste, liquid <br /> O Water and ail 001 Tr G <br /> R b <br /> 15 Special Handling Instructions and Additional Information Handling Codes for Wastes Listed Above <br /> 11a 11b <br /> Profile <br /> Do not ingest <br /> Wear protective clothing Invoice 7 72- <br /> In case of emergency call CHEMTREC 800-424-9300 Sales Order 1�4? � <br /> DOT ERG 171 <br /> 18.GE�IE�tAT[I1 481. 3ItRCATt�td certit+i the matelots deser(bed 4ova oR tttis i004 its not sojea to Male gLdeta�rell+�aticn�(es reparlmg Rroper dispose► lia�c o s a <br /> Printed Typed Name Signature <br /> T — -'r" f ter. <br /> �a Month <br /> a`Day Year r <br /> }s 71 � 7' -7 te " <br /> 01 Printednyped Name Signature Al <br /> of <br /> Month Day Year <br /> IS Orscrepancy indication Space <br /> rS <br /> ray f <br /> YRAf9 � 4 r� �N�TS! ,�Y�al'� 97�� � • ]l11VRSAIW;'�X.�i"R�`LL��1 3y x �' 1.-.A <br /> PrintedlTyped Name Signature <br /> Month Day Year <br /> WHITE—ORIGINAL(Retum to Generator) YELLOW--TSDF(Retain Copy) PINK—TRANSPORTER COPY GOLDENROD—GENERATOR'S COPY <br />