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j Evergreen Envi,_,imentai Services N� fi 5 2 4 6 dedicated to the protection of the environment To schedule a pickup, call Send payment to: Sales Order# 800-972-5284 Evergreen Oil,Inc. 6880 Smith Ave.,Newark,CA EPA#CAD9S2413262 Dept.LA 23234 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 Pasadena,CA 91185-3234 Date: GENERATOR/JOB LOCATION BILLING INFORMATION N ! NAME � CASH❑CHECK❑ # ADDRESS ADDRESS C••SATOMER CODE NO. 1:2 M L_3H�v l CIT .- STATE ZIP CO. CITY STATE ZIP CO. PO# PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. a Z - 19 PRODUCT WASTE MANIFEST CODE NUMBER QUANTITY UNITS PRICE AMOUNT Used oil,Non-RCRA Hazardous Lubricating CA2 Gal, Waste,Liquid Industrial CA221 Gal. Used Automo,ive Andfreue,Non RCRA Hazardous CA 134 Gal. wine L uid RQ wase Combustible Liquid,N.O.S.NA CA221 1993 HI(Oil comaminaled with halo=ens F001/F002 Gal. Oil&Water,Non-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 5 0/Specify Product Gal. Glycol But one./Specify Product Gal. TEST: .. Clor D Tech 4000_7.1__1ppm ❑Clor D Tech 1000 2rpass ❑Fail detain sample f#I Total ChargN equired Field Service Work Description: Other: Other: TS ❑/� Consolidated Manifest DR VIE Evergreen Oil,Inc. ❑ Evergreen Oil,Inc.-Davis❑ Evergreen Oil,Inc.-Fresno ❑Time In Time Out 6880 Smith Ave. Road 30B 4139 N.Valentine Newark,CA 94560 Davis,CA 95616 Fresno,CA 93722 ❑ Tank/Drum Properly Labeled CAD980887418 CAD982446874 CAD982446882 ❑ Accumulation Start Date Marked ❑ Evergreen Env.Svc. HWrp t08,I1tc-SmtaMaria❑ ❑ House Keeping-Tank/Drum Clean 16604 S.San Pedr 745 A West Betteravia ❑ Other Services Checked: E3Oil, ❑ Filters/Drums, ❑Antifreeze Carson,CA 907 Santa Maria,CA 93454 CAD9816964 CAD982446858 10 Called in other services needed ❑Oil, ❑ Filters/Drums,❑Antifreeze Source: Collection Station U 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 practicable. I hereby certify that I have read and have the anthoriU to bind the above listed generator to the terms on the reverse side of this form. IMPORTANT NOTICE REGARDING THE DISPOSITION OF YOUR OIL. Per California Health 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 comply with the more stringent requirements applicable to hazardous waste management facilities.California facilities that handle or process used oil are required to meet those more stringent requirements,and some out-of-state facilities that process used oil also meet those requirements. These include more stringent leak detection and prevention requirements,engineering certifications of tank integrity,and financial assurances for clo 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 an of these more stringent requirements.This notification is for information purposes only. - river Signature rint Name Route# Date f Generator's Si -nature Print Name Date White Copy--Customer Copy-Pink&Yellow Copy--Office Use-Green Copy=Attach to manifest-Golden Copy--Driver Copy