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Dec 18 08 03: 53p R""7RD (20-' 644-8555 p. 2 <br /> J <br /> tEvergreen <br /> Environmental Sery Icl3s N° 20765 <br /> Contarnerrzed Services <br /> !� dedicated to the protection of the environment <br /> To schedule a pickup, call Send pa;,tat nt to: Sales Order# <br /> 800-596-9455 Evergreel 0:1,Inc. <br /> 6880 Smith Ave..Newark,CA EPA#CA0982413262 P.O. BC,*. A517 <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 Los Angeles,t .a 30030 0517 Date: I <br /> GENERATOR/JOB LOCATION BILLING IN.='C RNIATION <br /> NA ENAME <br /> i~AIV� V(l CASH CHECK <br /> _ # <br /> C f' <br /> ADDRESS_ ADDRESS C(!SI�iIF-RZCODE NO. <br /> Z` r)ryw.r 1 �--{{ <br /> CITY STATE ZIP CO. CITY STATE zu, CO. PO# <br /> PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> Waste Latex Paint(Non-RCRA) <br /> Waste Latex Paint(Non-RCRA) <br /> Witstc Paint Related(Flatnmables oil based) <br /> Waste Paint Related(blammables oil based) <br /> Waste Aerosols Cans <br /> M."T tluznnbars W;uta,solid Is"' <br /> Ddl- IWU!i.Cd Wnh caoluum D llmeart—o <br /> Nnn-ItC'R-\Idaiaolnu..wuuiu,solid 1&,il. -- <br /> nchrin eunraminand Wish •Imleum h•dn¢-rr6�ms1 _ <br /> Waste Corrosive Liquids,n.o.s. <br /> Waste Hainmable 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 /> Waite Oxidizing Liquids or Solids <br /> Drained Used Oil Filters <br /> Empty Drums - - <br /> Non Hazardous Water <br /> Non liazardous Water <br /> Nun Hazardous Solids <br /> Non Hazardous Solids <br /> Glycol Bulk 50150 <br /> Glycol Bulk Cone. <br /> (A-S&G' �i lS Q C CGr7i%c+cYzZ <br /> I <br /> TOTAL CHARGES <br /> TSDF <br /> Everercen Oil,inc. CPR ❑ __ <br /> 6880ySmith Ave. 0 33210 Westem <br /> Newark,CA 94560 Union City,CA 94587 <br /> CAD980887418 CAL000091507 <br /> Source: L)Collection Station L]Government quantity <br /> cent lies that it hili established a program to reduce the volume or <br /> quantity&toxicity of the huzardous waste to the degree detcmrined by <br /> ❑Marine ❑ Agricultural C1 Industrial generator to be economically practicable. - <br /> 1 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 'HE DISPOSITION OF YOUR OIL. <br /> Per California Health and Safety Code Section 25250.9,Everstrecn here -y idvises customer that customer's shipment of used oil may be <br /> transported to a facility that is required to comply with federal regulations ipflicable to management of used oil,but that is not required to <br /> comply with the more stringent requirements applicable to hazardous wast) m tnagement facilities.California facilities that handle or process used <br /> oil are required to meet those more stringent requirements,and some out-c• st ite facilities that process used oil also meet those requirements. <br /> These include more stringent leak detection and prevention requirements,a igi leering certifications of tank integrity,and financial assurances for <br /> closure and accidental releases. It is lawful to send used oil to out-of-state ',tc lities that comply only with federal used oil management standards <br /> and not these more stringent requirements.This notification is for informal un purposes only. <br /> �r -�- -i!.2.ein � tr.-�jry��. '�- )�7• X L--' .i.•1`.ij L�-'''//:;=''%�i '� i l� :J u <br /> Driver Si na a Print Name Route# Datt Generator's Signature Print Name Date <br />