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V VW 1v V Lverg]'eell Vl1.Inc: 1/1/)[�(-/ <br /> 6M sr mr A, Ne,.:rk,CA L1:A#CAD982r1 Dept.LA 23234✓V O (^2-7r <br /> J ) t <br /> 16540 S S:n Pedro Sr,Carson CA EPA#CAD932413262 Pasadena,,CA 91145-3234 Date:\"—/r 1 c> <br /> GENE]ZA7'OR/JOI3 LOCATION BILLING INFORMATION <br /> N 11E ", CASH{] CHECK❑ <br /> ADDRESS ADDRESS CUSTOMER CODENO. <br /> CITY STATE ZIP CO. -CTI'P STATE ZIP CO. PO fF <br /> 77 <br /> C4 9T3 I <br /> PHONE NO.1 PHONE NO. PROFILE NO. C TOMrR,EPA 11)NO. <br /> (Zws SLS- . 1S t ) >1 Cl< <br /> PRODUCT WASTE MANIFEST <br /> CODE NUMBER QUANTITYQUANTITYUNITS PRICE � AA40UNT <br /> - <br /> Used oil,Non-RCRA.Aazardons i,tibricating. CA22 V� Gal. <br /> Waste,Liquid hidusaial CA221 Gal. <br /> . . . <br /> ukaA�mI.rAnnar�s.v n.acxA.Iruru,aw. <br /> w. CA73 -- '.. Gal. <br /> C' wa ' <br /> nU\YvM CninboniUk4tqub.N.OS.M CA221` <br /> 1 ]111 an mnnnmmea•fin onto oK roolrcaox Gal. <br /> Oil&Water,Non-RCRA Hazardous Waste Liquid CA223 Gal. <br /> Non Hazardous Water Gail. <br /> Waste solids and:Sludges Gal. <br /> Valli Out Each <br /> PfessurelVasltedsteam Cleaner Day <br /> Transportnlion HtS. <br /> -Pudl urchlage '% <br /> G1ycol'Bulk 5 .O 4mjfyProducl Gal, <br /> Glycol l3Bl r1nJSpeeify:Prodnct Gal. ` <br /> 'TEST: ' -CI&D Tech 400A% —ppm-.❑Clor D Tech 1000 6Pass❑:Pail ❑Pass ❑ Enil <br /> Retain sample## s1 `Felt it Charges <br /> Required,. ., ._C - L4 <br /> Rield'service Work Description: <br /> Other. <br /> Out on <br /> TS Consolidated Manifest 12]2T4'3;(2 II�.GI{LIS'C <br /> Evergreen Oil,Inc:. Evergreen 09,Inc.-Davis❑ Evergreen Oil,Inc.rFMS110 ❑`nme In Time Out1:1 _ <br /> 6880 Smith Ave. Road 30E 4139 N.Valentine. <br /> Newark,CA 94560 Davis,CA 9561.6 Fresno,CA 93722 ❑ Tank/Dnun Properly Labeled <br /> CAD080887418 CAD982446374 CAD982446882 Q Accumulation Start Date Marked - l_ <br /> Evergl'een❑ Lmv.Svc./' Eiap=Mlne-SandhfalaF t❑ Horse Keeping-Tank/Drtuli Clean 1660{S.San Pedu!' 745 A.West Betteravia II Other Services Check d: O Oil, D FiReisiDmins,Q Antifreere <br /> Carlon CA <br /> CAD982446858. ervxCA 9Q7//16 Santa Nlaria,GL 93454 <br /> CAD91 ❑ Called in otherscs neuAud Cl Oil, ❑ FiterslDruneze,ls, pAntihe6� V- <br /> Generator certifim that it has established a program to reduce the volume or <br /> Source: Collection Station ❑ GOvenument quandiy&toxicity of the hazardous waste to the degree determined by <br /> ❑IVItIRne ❑ Agricultural ❑ Industrial 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-QLt els form. - - <br /> IMPORTANT NOTICE RF,GARDING TIIF DISPOSITION OF YOUR OIL. <br /> Per:California Health and Safety,Code Section 25250.9,Evergreen hereby advises customer that customer's shipment of-used oiltnny be <br /> transported to a facility that is.required to comply with federal;regulatici mapplicabie to management of used ail,but that is not regpired to <br /> comp with the more stringent requirements applicable to hazardous waste management facilities.California facilities that handle or process used <br /> oil aleequired 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 tankintegrity,and financial assurances for <br /> closu>'c'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 ndt these more stringent reLrements.'rhis' notification is for information purposes only . <br /> r <br /> Driv*Signature Pant Name Route!{ Date aerator's Signature Print Name Date <br /> lj While Gouv=Custnmrr i,nnv- Pink R Yellnw Cnzw=O flCp.I IFA-.(irP.gp r:nnv=At1ACh to m2nifRCY-(i'lldFrl('.(nn\;-llrivgf r'.rrt:. <br /> 3 t <br />