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.r-..� ....i_�rnn ^^T.^� ,� �.,yw,Iy ,f.Tne•��• �+ -SAY <br /> ti <br /> 1 I Generators US EPA ID No 2 Page 1 3 DOeu< 1Of <br /> Number <br /> M- N 131 3 <br /> a �a <br /> a Generators Name and Mailing Address EES 19 <br /> 13 01 C4 <br /> Generator's Phone ` <br /> 5 Transporter Company Name 6 US FPA 10 Number 7 Transporter Phone <br /> EVERGREEN ENVIRONMENTAL SERVICES <br /> CAD982413262 800-972-5284 <br /> 8 Designated Facility Name and Site Address 9 US FPA ID Number 10 Facillty's Phone <br /> Evergreen 011, Inc <br /> 6880 Smith Avenue <br /> G Newark, CA 94560 CAD980887418 510-795-4401 <br /> N tainer <br /> I 1 Waste Shipping Name and Description 12 Cons I s 14 <br /> tal unit <br /> E No I Type ou"tity WWol <br /> R a <br /> A onN Hazardous ste, liquid <br /> o Water n al <br /> 001 TT G <br /> R b <br /> 15 Special Handling instructions and Additional Information Handling Codes for Wastes Listed Above <br /> 11e 11b <br /> Profile# <br /> Do not ingest <br /> Wear protective clothing Invoice '7/4W6 f <br /> In case of emergency call CHEMTREC 800-424-9300 Sales Order <br /> DOT ERG 171 <br /> r,,r,,,r. fry 4 k fl 5 i c� Ar ]�,w <br /> 16 GENERAT0WSCIWRT�FICATIQM!4 WwAxi <br /> Printed/Typed Name / Signature ;�1 <br /> T �j'� /� ���/ Mon Day Year <br /> R � N �C.► .per <br /> A <br /> 5 17.TransporteW AIoiOiN� ►9rH <br /> R <br /> O PnntedrTyped Name Signature <br /> TMonth Day Year <br /> 18 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> L <br /> l <br /> R <br /> PdntedRyped Name Signature <br /> Month Day Year <br /> WHITE—ORIGINAL(Return to Generator) YELLOW—TSOF(Retain Copy) PINK—TRANSPORTER COPY GOLDENROD—GENERATOR'S COPY <br /> s <br />