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I Ar <br />RECEIVED N28 <br />�3Evergreen Environmental Services <br />0 Containerized Services NOV 0 4 2013 <br />dedicated to the protection of the environment <br />Ir To schedule a pickup, call Send payment to: <br />�' les Order # <br />800-972-5284 Evergreen Oil, IgNVIRONMEE TAIL <br />6880 Smith Ave., Newark, CA EPA# CAD982413262 Dept. LA 23234 <br />16540 S. San Pedro St., Carson, CA EPA# CAD982413262 Pasadena, CA 91185-3234 Date: <br />GENERATOR/JOB LOCATION BILLING INFORMATION <br />NA NAME CASH Q CHECK <br />6r # <br />ADDRESS ADDRESS CU�TQT )VR CODE NO. <br />C ' S'rATl' -4IP C.O. CITY STATE ZIP CO. PO # <br />rnuiNh , iQ' ��� I PHONE NO, I PROFILE NO. CUSTOMER EPA ID NO. <br />PRODUCT WASTE MANIFEST <br />CODE NUMBER <br />QUANTITY UNITS PRICE AMOUNT <br />Waste Latex Paint (Non-RCRA) <br />Waste Latex Paint (Non-RCRA) <br />Waste Paint Related (Flammables oil based) <br />Waste Paint Related (Flammables oil based) <br />Waste Aerosols Cans <br />Non-RCRA Hazardous Waste, Solid (Soil, <br />Debris contaminated with troleum h drocnrbons) <br />Non-RCRA Hazardous Waste, Solid (Soil, <br />Debris contaminated with petroleum hydrocarbons) 99 <br />1A <br />Waste Corrosive Liquids, n.o.s. <br />Waste Flammable Liquids, n.o.s. <br />Waste Flammable Liquids, n.o.s. <br />Non-RCRA Hazardous Waste, Liquid <br />Non-RCRA Hazardous Waste, Liquid <br />Waste Toxic Liquids or Solids (Class 9) <br />Waste Oxidizing Liquids or Solids <br />Drained Used Oil Filters <br />Empty Drums <br />Non Hazardous Water <br />c <br />Non Hazardous Water <br />Non Hazardous Solids <br />Non Hazardous Solids <br />Glycol Bulk 50/50 <br />Glycol Bulk Conc. <br />TOTAL CHARGES <br />TSDF <br />Evergreen Oil, Inc. ❑ SA Recycling <br />6880 Smith Ave. 33210 We <br />Newark, CA 94560 Union City, CA 94587 <br />CAD980887418 CAL000344530 <br />Generator certifies that it has established a program to reduce the volume or <br />Source: L)Collection Station ❑ Government quantity & toxicity of the hazardous waste to the degree determined by <br />❑ Marine ❑ Agricultural L] Industrial generator to be economically practicable. <br />Retain sample # <br />I here certtry that i nave read and have the authority to <br />bind the above listed generator to the terms on the reverse <br />side of this 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 facilit that is required to comply with federal regulations applicable to management of used oil, but that is not required to <br />comply with th re s rmgent requirements applicable to hazardous waste management facilities. California facilities that handle or process used <br />oil are requ' to mee those more stringent requirements, and some out-of-state facilities that process used oil also meet those requirements. <br />These i ude mores 'ngem 1 k etection and prevention requirements, engineering certifications of tank integrity, and financial assurances for <br />clost and accident rel lawful -send used oil to out-of-state facilities that comply only with federal used oil management standards <br />an not these more t ' nt eme . This notification is for information purposes only. <br />VI a� r <br />/ l L3 <br />Driver Sivnatnre Print Name Rnnt,-.ff <br />