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* *Generator, Mail a copy to: DISC P.O. Bax 400 Sacramento, Ca. 95812.0400 within 30 days.** <br />Please print or type. (Form designed foruss on e8te (12-pldch) typewriter.) FormAonroved. OMS No. 2050-DD39 <br />isaForm 87W22(Ray.3-05) rmvimasadmonsamobsolete. 11MNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS 1. Generator m Numbor <br />C. ©16Z <br />2. Fago ! of <br />1 <br />3. Emergency Response Phony <br />4. onUeslTrnck ng Num or <br />JJK <br />WASTE MANIFEST ;IIAI �W <br />1 <br />800- <br />42656 <br />b.GenanettoorsNome and Moiling Address – �rl Generators elle Address (tfdifferentthanmallingaddress) <br />Generators Phone, <br />e. TmnSmder 1 Company Name U.S. EPA 10 Number <br />Ever reen Environmental Services ' CAD982413262 <br />7.Tamspoder2CflmpenyNome US.EPA I -Number <br />8. Deslgnaled Facility Name and Stliki ss U.S. EPAIDNumber <br />Evergreen Oii, Inc. <br />6880 Smith Ave. CAD980887418 <br />Newark, Ca. 94880 <br />•Fadlitys pirate: <br />ga. <br />HM <br />9b. U.S. DDT DescriplInn Qocludtng proper Shipping Nome, Hazard Class, ED Number, <br />acrd Packi Gf <br />�mu 0 �Y)) <br />10. Centel To <br />11.Totat <br />12. Unit <br />13. Waste Codes <br />Na <br />Type <br />p <br />CuanO[y <br />WtNal. <br />us <br />C9 <br />3: <br />4. <br />14,Speclat andl[off laslacgonsandAddiflonalkdormnBon tap <br />16. OENERATOR'SIOFFEROWS CERFIFICAMON: I hereby fthue that the contents of this consignment are Wily and accurately dosvibed above by the propersbrppfag name, and me classilled, packaged, <br />marked and faboladfplacardA and ars in all raspecls In propor condition Wrbansport according to applicable dnlemalional and nalbrral govarrinim l reaufatfons.lf export shiprrentand I am the Primary <br />Exptxtsr, (codify that lire consents of Ihts exatsigrrmant oort8mm to the terms of the ottaclred EFAAeknowiedgment of Consent. <br />I eediry that Bre Waste minimization statemardidar 9fied in40 CFR 262.27(a) (ir I am a large quantity generator) or(b) (01 am a small quantity generator true, <br />GanoraWs flsrers Nmaa Signalu Month ay Vere <br />re , I 11212.(I(l <br />*f <br />�.0 <br />F– <br />16, In orrel carmen <br />❑ Import to U.S. ❑ <br />Export from U.S. Po eatryfexlk E <br />Transporters�nakma (tar exports rn W: D laavirtg U.S; <br />17. Transpoder Admawledgment ofRecelpt of Motorists <br />Ttanapoder P dtlypsd ems re Month Day Year <br />Tmnspaterz P yp Name Slgr>akua Mangy - Day Year <br />i8.Discrepancy <br />l-1 <br />Ills. DiscreponzyIndication space ❑ Camotity ❑Tppa ❑Residue ❑PadlalRejedfon ❑FuBRole*, <br />MarifestReference Number <br />18b.Ahemeta Factlity (orfteratod U.S. EPA ID Number <br />81 <br />ii <br />Facitily's Phone., <br />180. Signature ofAilarnela Facilrly (or Generator) <br />Month Day Year <br />Q <br />z <br />1W <br />19. Hazardous Whsle Report Manegamant Method Codes (I.e., codas for hazardous waste treatment, disposal, and racyong systems) <br />0 <br />1 f,J6_ g <br />x <br />3• <br />4. <br />20.Oaslgaaled F/ocgdy" Owner arOpmolor: Certification of recaVl othazardeus matbdala covered by the manifest except as noted in Ilam 18a <br />Pd*&Typad NameSignature nth Oa Y <br />isaForm 87W22(Ray.3-05) rmvimasadmonsamobsolete. 11MNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />