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<br />.`/ Evergreen .Environmental Services No 411526
<br />dedicated to the protection of the environment
<br />To schedule a pickup, call Send payment to:
<br />Sales Order #
<br />800-596-9455 Evergreen Oil, Inc.
<br />8&30 Smith Ave., Newark, CA EPA* CAOM413202 P.O. BOX 30517 .
<br />16940 S- San Pedro 9t., Carson, GA EPA# CAD902413262 Los Angeles, CA 9003(%0517 Date:
<br />GENERATOR/JOB LOCATION BILLING INFORMATION
<br />NAM
<br />NAME
<br />CASH ❑ CHECK [J
<br />UNITS PRICE
<br />ADDRESS
<br />CUS O DE NO.
<br />ADDRESS
<br />Z
<br />Gal,
<br />Cl Y STATE ZIP CO.
<br />CITY STATE ZIP CO.
<br />PO #
<br />Gal,
<br />Wad AMM(Cle Anlifrseoe, Non-RCRA H-1—
<br />PHONE NO.
<br />PHONE NO.
<br />PROFILE NO.
<br />CUSTOMER EPA ID NO,
<br />RQ `A`am ComlvrJlete �y.e, Ii,Q,3. NA
<br />rvys to ,� .un n.t
<br />CA22 t
<br />soo11wo2
<br />Gal.
<br />PRODUCT
<br />WASTE
<br />CODE
<br />MANIFEST QUANTITY
<br />NUMBER
<br />UNITS PRICE
<br />AMOUNT
<br />Used oil, Non-RCRA Hazardous Lubricating
<br />CA22
<br />Z
<br />Gal,
<br />Waste, Liquid Industrial
<br />CA221
<br />Gal,
<br />Wad AMM(Cle Anlifrseoe, Non-RCRA H-1—
<br />CA 134
<br />Gal.
<br />RQ `A`am ComlvrJlete �y.e, Ii,Q,3. NA
<br />rvys to ,� .un n.t
<br />CA22 t
<br />soo11wo2
<br />Gal.
<br />Oil & Watcr, Non•RCRA Hazardous Wastc Liquid
<br />CA -121
<br />Gal,
<br />Waste Solids and Sludges
<br />Gal.
<br />Wash Out
<br />Each
<br />Drained Used Oil Filters
<br />Drum
<br />Non-RCRA Hazardous Waste Solids (oily debris)
<br />CA223
<br />Drum
<br />Empty llnrms
<br />Drum
<br />'ltansportation
<br />Hrs.
<br />Non HaLardous r
<br />Gal.
<br />Olycol Bulk 50150
<br />Gal,
<br />Glycol Bu Conc,
<br />Gal,
<br />TEST: Yclor D Tech 40t10ppm ❑ ClorD Tech 1000
<br />Pass ❑Fail ❑Halogen Detector/RamTest Pass ❑Fail
<br />Field Service Work Description:
<br />Total Charges
<br />Other;
<br />Other:
<br />Vacuum Wices Timc
<br />Out of Y On Site Off Site
<br />Off Load Start Off Load End
<br />eturn to Yard
<br />TS1 17Consolidated Manifest
<br />F3vergrcen Oil, lac. livcrgrccn Env. Svc. ❑ Evergrge,m F,nv, Svc. ❑ AJS Filter
<br />6880 Smith Ave, Rnad 30H 4139 N. Valentine 15131 Clark Ave.
<br />Newark, CA 9410) Davis, CA 95616 Firrsno, CA 93722 Industry, CA 91745
<br />CAWNW87418 CAU982446874 CAD982446M2 CAD000097432
<br />❑Evergreen Env. S ❑ Evergeen Env. Svc- J CFR ❑ CFR ❑ Greenleaf Env. Svc,
<br />16604 S. Sart 745 A West Betteravia I_ J 944 E. SFauson Ave. 33210 Wester 3474 Toyon Circle
<br />Carson, CA 46 Santa Maria, CA 93454 Los AAnnggeles, CA 9(101 I Union City, CA 94587 Val] Springs, CA 95352
<br />o009
<br />CAD98169 o, - CAD982446858 CALM0110021 CAL01507 CAL000214411
<br />Generator certifies that it leas established a program to reduce the volume or
<br />Source: Collection Station ❑ Government quantity & toxicity of the hazardous waste to the degree determined by
<br />O Marine ❑ Agricultural ❑ Industrial generator to be economically practicable.
<br />I herehy Certify that I have read and have the authority to
<br />bind the above listed Renerator to the terms on the reverse
<br />Retrain sample # / side of thea form.
<br />IMPORTANT NOTICE REGARDING THE DISPOSITION OF YOUR OIL„
<br />Per California Health and Safety Code Section 25250.9, Evergreen hereby advises customer that customer's shipment of used oil may be
<br />transported 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 process used
<br />oil arc required to meet those more stringent requirements, and some out-of-state facilities that process used oil also meet those requirements.
<br />T include more stringent leak detection and prevention requirements, engineering certifications of tank integrity, and financial assurances for
<br />C su and accidental releases. it is lawful to send used oil to out-of-state facilities that comply only with federal used oil managerneut standards
<br />d n t these more stringent re ircmcnts. This notification is for information purpo only.
<br />
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