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Please print or type.(Form designed for use on elite(12-pitch) _..writer.) �orem Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Ge tar ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number JJ K WASTE MANIFEST A?- c1 1 1-800-42iling 4-9300 g address)Q 6 6 5.Generator's Name and Mailing Address Generator's Generators Site Address(if different than ma Generat0 s hone: U.S.EPA ID Number 6.Transporter 1 Company Name CAD982413262 Evergreen Environmental Services U.S.EPA ID Number --7-Transporter-Company-Name - - - - 8.Designated Facility Nome and Site Address U.S.EPA ID Number Evergreen Oil, inc. � 6880 Smith Ave. CAD980887418 Newark,Ca.94560 Facility's Phone: 510-795-4400 M7 ya 9b.U.S.DOT Description(including Proper Shipping Name, azarass,Hd ClID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. o z 2. W 0 3. 4. 14.S ecial�Handling Instructions and Additional Information _ / �_>� � 6 3- 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. ify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quanfity generator I or(b)(if I am a small quantity generator)is true. Gento Offerors Print ped Name Sig to Month Day Year �, 1 1 � 11 16.Inte atfd a ipm nts ort from U.S., Port of entry/exit: Ex Import to U.S. ❑ P Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials LLJ� Transporter 1 Printed/Typed Name Signa Month Day Year � � � 9L Month Day Year Za Transporter 2 Printedrryped Name Signature t- 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J V Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z �CD-, 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) r 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)