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* Evergreen Divx_ __amental Services N°_ 685023 <br /> v dedicated to the protection of the eiviromuert <br /> To schedule a pickup,call Send payment to: Sales Order# <br /> 800-972-5284 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 /> GENERATORIJOB LOCATION BILLING INFORMATION <br /> NAME , NAME CASH Q CHECK❑ <br /> ADDRESS ADDRESS CU TOMER CODE NO. <br /> CITY STATE ZIP CO. CITY STATE ZIP CO. PO# <br /> —CA jr <br /> ozs -S <br /> PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA EI)NO. <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE L� <br /> CODE NUMBER <br /> Used oil,Non-RCRA Hazardous Lubricating CA22 �SZ � Gal. <br /> Waste,Liquid Industrial CA221 Gal. <br /> Used Automotive Antir==,Non-RCRA Hazardous CA134 Gal. <br /> Wute Liquid <br /> RQ Write Combustible Liquid,N.O.S.NA CA221 G.� <br /> 1993 In(Oil mntominared with holoeens) F001/F002 <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 I;irs, <br /> Fuel Surcharge % <br /> Glycol Bulk 50/50 pecify Product Gal. <br /> Glycol Bulk ncJSpecify Product Gal. <br /> TEST: , Clor D Tech 400a,=�­ppm ❑Cior D Tech 1000 - Pass ❑Fail <br /> Retain sample# Total Char es <br /> Re aired 77 G <br /> Field Service Work Description: <br /> Other: <br /> Other. <br /> TSD Consolidated Manifest DRIVER C CK�IST <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 <br /> Newark,CA 94560 Davis,CA 95616 Fresno,CA 93722 ❑Tank/Drum Properly Labeled <br /> CAD980987418 CAD932446874 CAD982446882 ❑ Accumulation Start Date Marked <br /> ❑ Evergreen Env.Svc. ElE++et°�tMlnc.-Se. Kffia❑ ❑House Keeping-Tank/DruraClean <br /> 16604 S.San Pedro 745 A West Betteravia ❑ Other Services Checked: ❑Oil, ❑ FiilterslDrums, ❑Antifreeze <br /> Carson,CA 90Santa Maria,CA 93454 <br /> CAD98169642746 CAD982446858 10 Called in other services needed El Oil, ❑ FilterslDrums,❑Antifreeze <br /> Generator certifies that it has established a program to reduce the volume or <br /> Source: CaCollection Station ❑Government quantity&toxicity of the hazardous waste to the degree determined by <br /> ❑Marine j Agricultural ❑ 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 /> 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 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 financial assurances for <br /> CIO sure nd accidental releases.It is lawful to send used oil to out-of-state facilities that corn y only with federal used oil management standards <br /> and no ese more stringent requirements.This notification is for information;Gene <br /> rposes onl <br /> Dri r Signature Print Name Route# Date r tor's Signature Print Name Date <br /> White Copy=Customer Copy-Pink&Yellow Copy--office Use-Green Copy='Attach to manifest-Golden Copy=Driver Copy <br />