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WORK ORDER/SERVICE AC:Kr:.EMEIN'1 <br />Evergreen Environmental Services N� 4 6V 8 8 <br />dedicated to the protection of the envirorunent <br />To schedule a pickup, call Send payment to: Sales Order # <br />800-596-9455 Evergreen Oil, Inc. <br />6880 Smith Ave., Newark, CA EPA* CAD982413262 P.O, BOX 30517 <br />16540 S. San Pedro St., Carson, CA EPA# CAD982413262 Los Angeles, CA 90030.0517 Date: <br />r_1WMVn A TnW 1 Tnn If AV A TI"N RIT.I.rNr. rNFORMATION <br />N -- _ - —_ _ _ , <br />/ir <br />NAME <br />CASH ❑ CHECK [] <br />AD PMS <br />ADDRESS <br />CIJWONIP COOF NO. <br />V14 <br />,��� <br />Gal, <br />Waste, Liquid Industrial <br />CI STATE ZIP CO. <br />CITY STATE, ZIP CO. <br />PO # <br />Used Awm 'o AAf—, N—RCRA Hoa 1— <br />Was i�l <br />CA134 <br />PHONE NO, <br />PHONE NO. PROFILE NO. <br />CIJSTOMER EPA ID NO. <br />Gat. <br />Gal. <br />Writs Solids and Sludges <br />PRODUCT <br />WASTE <br />CODE <br />MANIFEST QUANTITY <br />NUMBER <br />UNITS PRICE AMI OUNT <br />Uscd oil, Non-RCRA Hazardous Lubricating <br />CA22 <br />,��� <br />Gal, <br />Waste, Liquid Industrial <br />CA221 <br />Gal. <br />Used Awm 'o AAf—, N—RCRA Hoa 1— <br />Was i�l <br />CA134 <br />GaL <br />RQ w,,,G.nhuulWe uqufa, N.O.S. rvA�' <br />IY'J) W rUil coo wi <br />Oil & Water, Non-RCRA Hazardous Waste Liquid <br />CA221 <br />Gat. <br />Gal. <br />Writs Solids and Sludges <br />(jai. <br />Wash Out <br />Each <br />Drained Used Oil Filters <br />Dnim <br />Non-RCRA hazardous Waste Solids (oily debris) <br />CA223 <br />Drum <br />Empty Drums <br />Drum <br />Transportation <br />Hrs. <br />Non HarardnUS to <br />Gal. <br />Glycol Bulk 50/50 <br />Gal. <br />Glycol Bu Conc.Cal. <br />TEST: Clor D Tech 4f100Z30—pprtl r-1CIO,n Tech 1000 <br />Pass ❑ Fail ❑ Halogen lletecturf9ame Test sg ❑ Bail <br />Field Service Work Description' <br />Total Char es <br />Other: <br />Other: <br />Vacuo Services Timc <br />outn Yard On Site Off Site <br />Off Load titan Off Load End <br />Rc <br />TSF <br />I'vergrecn nil, Inc. <br />6880 Snath Ave. <br />Newark, CA 44560 <br />CAD980887418 , <br />Evergreen Env. Svc. <br />Road 3OB <br />Davis. CA 95616 <br />CAD982446874 <br />Z Consolidated Manifest <br />i1 Everg=n Env. Svc,❑ AJS Filler <br />U 4139 N. Valentine 15131 Clark Ave- u <br />Fresno, CA 93722 Industry, CA 91745 <br />CAD982440882 CAD00009743. <br />EvergreenV20 <br />c. ❑ Evergreen Env. Svc. ❑ CFR ❑ CFR ❑ Greenleaf Env, Svc. <br />lt—J1 16604 S. v 745 A West Bettcrawia 944E Slauson Avc. 13210 Western 3474 'I'oyon Circle <br />Carwn, CSanta Maria, CA 93454 1 os Anggcles. CA 90011 Union City, CA 94587 Vail Spprings, CA 95152 <br />CAD9816 CAD982446858 CAI0001f0021 CAL000091507 CAU)tN1214411 <br />Generator certifies that it has established a program to reduce the volume or <br />Source: Collection Station LlGovernment quantity & tonicity of the hazardons waste to the degree determined by <br />❑ Marine ❑ Agricultural 0 industrial generator to be economically practicable. <br />I heretry certify that I have read and have the authority to <br />hind the above listed generator to the tertn_s_ on the reverse <br />Retain sample # side of this form. <br />IMPORTANT NOTICE REGARDING THE DISPOSITION OF YOUR OIL. <br />Per California Health and Safety Code Section 2.5750.9, Evergreen hereby advises customer that Customer's shipment of used oil may be <br />ti-ansportcd to a facility that is required to comply with federal regulations applicable to management of used oil, but that is not required to <br />comply with the more stringent requirements applicable to hazardous waste management facilities. California facilities that handle or pr�eess used <br />oil are required to meet those more stringent requirements, and some out-of-state facilities that process used oil also meet those requirements. <br />hese include more stringent Icak detection and prevention requirements, engineering certifications of tank integrity, and financial assurances for <br />losurc and accidental releases. It is lawful to send used oit to out•of•statc facilities that comply only with federal used oil management standards <br />d not these more stringent requirements. This notification is for information purposes nly, <br />