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Form ADDroved. OMB No. 2050-0039 <br />rrease <br />pnrn ui rypm trvnn uca: <br />UNIFORM HAZARDOUS 1. Generator lD Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest nN or <br />WASTE MANIFEST i., ' <br />5. Generator's Name and Mailing Address Genefator's Site Address (if different than mailing address) <br />4 r �Zkr� qry ac � - <br />8 <br />Carr&\4 <br />6. Transporter 1 Company Name " U.S. EPA ID Number <br />CAD98MVINg <br />EVERGREEN ENVII , NNI NTAL SERVICES <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8: Designated Facility Name and Site Address - U.S. EPA ID Number - <br />I rFAC38 E'N OIL, INC.. <br />tl Smith v� N w rk, Ca. 94,6 CAMS 87415 <br />51 €-796o4400 <br />Facility s Phone: <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Noi. <br />0 <br />1 <br />IwzON RCR HAZARDOUS WASTE, , LIQUID <br />001 <br />123- <br />a <br />UJI <br />2. <br />0" <br />i <br />3. <br />PE <br />4. <br />14. Special Handling Instructions and Additional Information <br />_ <br />_ <br />N10F�IL ... .. , . INVOICE # <br />DOT r=RG# 171 WEAR PnOTEOTIVE CLOTHINGSALES ' 02-'C6 AX <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby.dedare thatthe contents of this consignment are fully and:accurately described above by the proper shipping name, and are dassified, packaged, <br />marked and labeled/placarded, and arwin all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the,attached EPAAdmowledgment of Consent: <br />I certify that the waste minimization statement idenfified in40 CFR 262,27(a) (if I am,alarge quantity generator) or (b) (if I am a small quantity generator) is true: <br />Generatoes/Offemrs Printed(Typed Name Signature ` Month Day Year <br />1 v ,t/ 1QWCQ10 <br />J <br />[� <br />18: international Shipments` <br />Import to U.S. R Ex rt from U.S. Port of entrylexit: <br />= <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. Transporter Acknowled ment of Receipt of Materials <br />II <br />Transporter b Printed/Typed, Name t p Signature Month Day Year <br />a <br />QTransporter <br />2 PdntedlTyped Name Signalure Month Day Yead' <br />RL' <br />H <br />18. Discrepancy <br />18a. Discrepancy Indication Space 0 QuantityType ❑ yp El Residue ❑Partial Rejection ❑ Full Rejection <br />Manifest Reference Number.- <br />umber:18b. <br />18b.Alternate Facility (or Generator) U.S. EPA ID Number <br />W <br />Facility's Phone: <br />W <br />18c:' Signature ofAiternateFacility (or Generator) . Month ay- Year <br />Q <br />- <br />z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste' treatment, disposal, and recydinb systems) <br />Im <br />1: r - <br />Iq <br />12. <br />20. D t nated'Facil ty Miner: or Operator; Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed NaK ol Month?ay Year <br />EPA Form 8700-22 (R v.' 5)' reVious'editiotis are obsolete: DESIGNATED' FACILITY TO GENERATOR <br />