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vl Ayr X� , tiv1V.L•rv1Lr� 1 <br /> J Evergreen En viWmental Services No 579988 <br /> dedicated to the ro Ion of the environment <br /> To schedule a pickup, call Send payment to: Sales Order# <br /> S 800-596-9455 Evergreen Oil,Inc. <br /> 6880 Smith Ave.,Newark,CA EPA#CAD982413262 Dept.LA 23234 /^ 1 <br /> 16540S.San Pedro Sc,Carson,CA EPA#CAD982413262 Pasadena,CA 91185-3234 Date: �'� �✓ <br /> GENERATOR/JOB LOCATION BILLING INFORMATION <br /> AME1. _ *d NAME CASH Q CHECK❑ <br /> 1� # <br /> ADDRESS ADDRESS CYSTOMER CODE NO. <br /> .5.7. fd <br /> I STA IP CO. CITY STATE ZIP CO. # <br /> 5-4 V-Z <br /> PH NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. <br /> ( ) <br /> 14A FIV3 40 <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> Used oil,Non-RCRA Hazardous Lubricating CA22 � / Gal. <br /> Waste,Liquid Industrial CA221 Gal. <br /> UEd Wo,,e Uecive Anufn:exe.,Non-RCRA HaraN <br /> , ous <br /> CA13 i Gal. <br /> 9p93 iii(O I comnmma m wYh hebaen<) FW 1'221 02 Gal. <br /> Oil&Water,Non-RCRA Hazardous Waste Liquid CA223 Gal. <br /> Non Hazardous Water Gal. <br /> Waste Solids and Sludges Gal. <br /> Wash Out Each <br /> Pressure Washer/Steam Cleaner Day <br /> Transportation Hrs. <br /> Fuel Surcharge Z % <br /> Glycol Bulk 50/ specify Product Gal, <br /> Glycol But onc./Specify Product Gat- <br /> TEST: Clor D Tech 40001A-ppm Clor D Tech 1000 Pass E]Fail <br /> Retain sample# , l Total Charges <br /> Required G7l <br /> Field Service Work Description: <br /> Other: <br /> Other: <br /> TS Consolidated Manifest DRIVERVIJZCKLIST <br /> Evergreen Oil,Inc. ❑ Evergreen Oil,Inc.-Davis❑ Evergreen Oil,Inc.-Fresno ❑ Time In Time Out <br /> 6880 Smith Ave. Road 30B 4139 N.Valentine ❑ Tank/Drum ProperlyLabeled <br /> Newark,CA 94560 Davis,CA 95616 Fresno,CA 93722 <br /> CAD980887418 CAD982446874 CAD982446882 ❑ Accumulation Start Date Marked <br /> ❑ Evergree/Sc. ❑ Esag�tW,Tnc.-Saitatvlarin❑ ❑ Housekeeping-TalilcNrum Clean <br /> 16604 S. 745 A WestBeneravia ❑ Other Services Checked: ❑Oil, ❑ Filters/Drums, ❑Antifreeze <br /> Carson, Santa Maria,CA 93454 <br /> CAD981CAD982446858 ❑ Called in other services needed ❑Oil, ❑ Filters/Drums, ❑Antifreeze <br /> Source: on Station ❑Government Generator certifies that it has established a program to reduce the volume or <br /> quantity&toxicity of the hazardous waste to the degree determined by <br /> ❑ Marine ❑ Agricultural ❑ Industrial COPY generator to be economically practicable. <br /> I hereby certify that I have 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 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 equired to meet those more stringent requirements,and some out-of-state facilities that process used oil also meet those requirements. <br /> The i clude more stringent leak detection and prevention requirements,engineering certifications of tank integrity,and financial assurances for <br /> clos re and accidental releases.It is lawful to send used oil to out-of-state facilities that comply only with federal used oil management standards <br /> and o these more stringenents.This notification is for information purposes only. <br /> t irem <br /> D ' er Signature tint Name Route# Date rator's Signature Print Name Date <br /> White Conv=Custorner Coov-Pink R Yellow Cnnv=Offica I lap.-GrAP.n(;nnv=Anach to manifaet-nnlrlan r'.nnv-n.h.o.r....,, <br />