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J' <br /> Evergreen EnviL, imental Services N° 32490 <br /> ContalnerIftill Services <br /> dedicated to the protectinn of the onvimnment <br /> To schedule a pickup, call Send payment to: Sales Order <br /> 800-596-9455 Evergreen Oil,Inc. n <br /> 13eeO Smith Ave..Newark CA EPA*CA0982413262 P.O. BOX 30517 AZO_O/ <br /> iP..S40 S.San Pefm St.,(:arson,CA EPA*CADW-41IMP Los Angeles.CA 90030-0517 Dat/ O <br /> GENERATOR/JOB LOCATTON BILLING INFORMATION <br /> NAME NAME CASH CHF,CF L <br /> �•�'E�L� ///lTl�b�- N <br /> ADDRFS_ ADDRESS CU OD�YO. <br /> CITY—� 5TATE; Co. CITY STATE 7.rr CO. roti <br /> PHONE N(a, � S C PHONE NO. PROFILE NO. CU OAiER FPA ID 50, <br /> PRODUCT WASTF. MANIFEST QUANTrrV UNITS PRICE AMOUNT <br /> CODE. NUMBER <br /> Wavle Latex Paint(Nun-RCRA) <br /> Wmro r.nrex Paint(NmRCRA) <br /> Waste Paint Related Mammablm oil Mscd) <br /> Waste Paint Related(Flammables oil based) <br /> Waste Aerosols Cam <br /> Ntn.R(RA ll n.-¢W.solid ISM. <br /> hb,ia cplTTina <br /> Nm-R A Nv.wem.wrarc,SnIW lsNl. <br /> Waste Corrosive Liquids.n.o.s. 1� <br /> Waste Flammable Liquids.mo.s, ,Q <br /> Waste Inammable Liquids,n,u.s. <br /> Nim-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 /> nraimil I.Isrrl Oil Fill R <br /> Empty Dmms Z <br /> Nom Hazunluus Water <br /> Nan Haramm]S Water <br /> Non Hazardous Solids <br /> Non Hazardous Solids <br /> Glycol Bulk 50/50 <br /> Glycol Bulk Colic. <br /> TOTAL CHARGES <br /> TST)W <br /> Evc]gmcn Oil.Inc. CFR Ar <br /> 6880 Smith Ava 33210 Western <br /> Newad(.CA 94560 Union Ciryry CA 94587 <br /> CAU9bU8tf/41x CAt.00W.1507 <br /> ('xmeatm ccrdncs that it has established a program to mduzv the volume or <br /> Source: ❑Collection Station ❑Government quimrity&tonicity of the hmarde]s waste in the dcence determined by <br /> ❑Marine ❑ Agricultural Q Industrial gencmtor to be cmneniwlly pmcdcable. <br /> I hercbv ccrtifV that I have read and have the aethority to <br /> bind the above listed generator to the terms on the reverse <br /> Retain sample # side of this form. <br /> IMPORTANT NOTICE REGARDING THE DISPOSITION OF YOUR OIL. h <br /> Per California Health and Safety Code Section 75250.9.Evergreen hereby advises customer that customer's shipment of used oil may be <br /> truosported to a facility that is mquimd to comply with federal regulations applicable to mamigemnnr of nseA nit. hat that is mit mritlired to <br /> comply with the more stringent requirements applicable to harurilouc waste management facilities. CalifOmia facilities that handle or process used i <br /> oil are required to meet thttso mom stringent requirements. and some out-of--state facilities that process used nil also meet Ihase requirements. <br /> These include more stringgcilt Icak dcteelion mkt prevention requircmrnts.engineering certifications of tank integrity. anti financial assurances for i <br /> closure and accidental rufcases. It is lawful to send used w1 to out-ot-state facilities that comply only with federal used oil managemem standards <br /> and not thew: more shin eat requirements. This notification is for information�u ^! . <br /> Chive Signarure Print Name Route 4 Date Generator's Signature Print Name Da(, <br />