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vvv Wvw v-rvv evergreen vll,rnc: 6880 Smith Ave.,Newark.,CA EPA#CAD98241 Dept, LA 23234�� 16540 S.San Pedm St.,Carson,CA EPA#CAD 3262 Pasadena,CA 91185-3234 • Date: "Z!" +7— — GENERATOR/JOB LOCATION BILLING INFORMATION NA.ME NAME CASH[:]CHECK❑ e^ ctiaw )VO> # ADS ESS E� ai ADDRESS CUSTOMER CODE NO. 3j poCITY STATE ZIP CO. CITY STATE ZIP CO. PO# 7 P ONE NO. PHONE NO. PROFILE NO. C t.TOMER F.PA ID NO. `tSi ( ) WASTE MANIF'F.ST PRODUCTWASTE NUMBER QUANTITY UNITS PRICE AMOUNT Used oil,Non-RCRA Hazardous Lubricating CA22 Ct ki:r.�T'L Gal. Waste,Liquid Industrial CA221 Gal. 111n¢Auwvnri-Amlrmeu,NOtiACAA fla"ar CA13 Gal. . WL' uia %QWwsncC twstllo lig04N.ox.NA (A22f 1g9J Ill Oil rawminaW»1i�tuio as Pootrtapz Gal. Oil&Water,Nen-RCRA Hazardous Waste Liquid CA223 Gal. Non.Hazardous Water GaL Waste Solids and Sludges Gal. Wash Out Each Pressure Washer/Steam Cleaner Day Transportation Hrs. Fuel Surcharge Glycol Bulk 5t 0/Specify Product GaL Glycol Bel oncApecify Product Gal. TEST: . . Clor D Tech 4IXH�ppm ❑Char D Tech 1000 Pass -]Fail Q Pass ❑Fail �. Retalll sample# �, 'notal Char«es Re u_i_red . 3 — Feld Service Work Description: Other: Otter: r� TS Consolidated Manifest I DRI lF R 'HIi CKLIST Evergreen Oil,Inc. Evergmen Oil,Inc.-Davit❑ Lvergreen Oil,Inc.-Fresno ❑ Time 111--rime Out _ 6880 Smith Ave. Road 30B 4139 N.Valentine p lank/Drum Properly Labeled Newark,CA 94560 Davis,CA 95616 Fresno,CA 93722 CAD980887418 CAD982446874 CAD982446882 1❑ Accumulation Star Date Marked Evergreen Env,Svc./f7 SaG Atzoa❑ ❑ House Keeping-7.hnk Drtm Clean 16604 S.San Ped 745 A West Betteravia r3 Other Services Checked '7 Oil, IJ Filters/Drums,G Amilreeye Carson,CA 907 V Santa Maria,CA 93454 - - CAD98iG9 - CAD982446853 L Called is other serviced needed Ll Oil, ❑ FiiliersBhums, ❑Anuhecze 1 Source: COiICCCIOn Station LJ Government Generator certifies that it has established a program to reduce the volume or quantity&toxicity of the hazardous waste to the degree determined by ❑ Marine ❑ Agricultural ❑ Industrial generator to be economically piacticable., i hereby certify that I have read and have the authority to bind the above listed generator to the terms on the reverse Sitieof th'tS form, IMPORTANT NOTICE REGARDING THE DISPOSITION OF YOUR OIL. Per California Healtb and Safety Code Section 25250.9,Evergreen hereby advises customer that customer's shipment of used oil may be transported to a facility that is required to comply with federal regulations applicable to management of used oil,but that is not required to comp)y with the more stringent requirements appLicable to hazardous waste management facilities.California facilities that handle or process used oil az$tequired to meet those more stringent requirements,and some out-of-state facilities that process used oil also meet those requirements. Thesdd t[elude more stringent leak detection and prevention requirements,engineering certifications of tank integrity,and financial assurances for closu 'and accidental releases.It.is lawful to send used oil to out-of-state facilities that compl only with federal used oil management standards and n tthese more stringent req 'rements.'Chis notification is for information purposes only. r Driv Signature Print Name Route# Date enerator's Signature Print Name Date White Cnnv=Customer Cnnv-Pink R Yallnw Cnnv_nfiinr I Ims-firwan CnnvvAnach to m,niinc}-t;nldnn Cnnv=rlrivor Cern;