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-Evergreen Enviror--nental Services N° 55730 <br /> dedicated to the protection of the environment <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 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 /> NAME CASH Q CHECK❑ <br /> # <br /> A DADDRESS CUSTOMER CODE NO. <br /> CITY �TATE CITY STATE ZIP CO. PO# <br /> PHONE NO. PHONE NO. PROFH.E NO. CUs OMER <br /> PRODUCT WASTE MANIFEST <br /> CODE NUMBER QUANTITY UNITS PRICE AMOUNT <br /> Waste Latex Paint(Non-RCRA) <br /> Waste Latex Paint(Non-RCRA) <br /> Waste Paint Related(Flans ables oil based) <br /> Waste Paint Related(Flammables oil based) <br /> Waste Aerosols Cans <br /> Non-RCRA Harm 9 Wane.Smoliumd(Soil. <br /> Demaen„ read wl,x wn a„tia,mnal <br /> Non.RCRAeHazardouc wazrc.Solid(Soil, <br /> Debra aonmminamd wiN troleumx drocubone ' <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 F rs <br /> Empty Drams <br /> Non Hazarous terd <br /> Non Hazardous Water <br /> Non Hazardous Solids <br /> Non Hazardous Solids <br /> Glycol Bulk 50/50 <br /> Glycol Bulk Cone <br /> TSDF TOTAL CHARGES <br /> Evergreen Oil,Inc. ❑ CFR /© <br /> 6880 Smith Ave. 33210 Western ❑ <br /> Newark,CA 94560 Union Ciry,CA 94587 <br /> CAD980887418 CA- 507 <br /> Source: ❑ Collection Station LJ Government Generator certifies that it has established a program to reduce the volume or <br /> quantity&toxicity of the hazardous waste in the degree determined by <br /> ❑ Marine- ❑ Ap ieultural ❑ Industrial 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 /> Retain sample# 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 requiregtents applicable to hazardous waste management facilities.California facilities that handle or process 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 /> These include more stringent leak detection and prevention requirements,engineering certifications of tank integrity,and frnaricial assurances for <br /> closure 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 not these more stringent requirements.This notification is for information purposes ort <br /> Driver Signature Print Name Route# Date Generator's Signature Print Name nate <br />