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Evergreen Envie Im en tai Sorvices <br />Containerized Services <br />dedicated to the protection of the errnironment <br />To schedule a pickup, Call. Send payment to: <br />o <br />800-596'9455 Evergreen Oil, Inc. <br />6880 Smith Ave., Newark, CA EPA# CAD982413262 P.O. BOX 30517 <br />16540 S. San Pedro St., Carson, CA EPA# CAD982413262 Los Angeles, CA 90030-0517 <br />GENERATOR/JOB LOCATION BILLING INFORMATION <br />Sales Or&r a# <br />Date: <br />NAME <br />PRICE AMOUNT <br />NAME <br />CASA Q CHECK <br />ADDRESS <br />Waste Paint Related (Flammables oil based) <br />ADDRESS <br />Waste Paint Related (Flammables oil based) <br />CUSTOMER CODE NO. <br />CITY <br />STATE ZIP CO. <br />CITY <br />STATE ZIP CO. <br />PO # " <br />PHONE NO. <br />Waste Corrosive Liquids, n.o.s. <br />PHONE NO. <br />Waste Flammable Liquids, n.o.s. <br />PROFELE NO. <br />CUSTOMER EPA ID NO. <br />PRODUCT WASTE MANIFEST QUANTITY UNITS <br />CODE NUMBER <br />PRICE AMOUNT <br />Waste Latex Paint (Non-RCRA) <br />Waste Latex Paint (Non-RCRA) <br />Waste Paint Related (Flammables oil based) <br />Waste Paint Related (Flammables oil based) <br />Waste Aerosols Cans <br />Non-RCRA Hazardous Waste, Solid (Soil, <br />Debris contaminated with petroleum hydrocarbons) <br />Non- RCRA Hazardous Waste, Solid (Soil, <br />Debris contaminated with etroleum h drocarbons) <br />Waste Corrosive Liquids, n.o.s. <br />Waste Flammable 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 />Waste Oxidizing Liquids or Solids <br />Drained Used Oil Filters <br />Empty Drums <br />Non Hazardous Water <br />Non Hazardous Water <br />Non Hazardous Solids <br />Non Hazardous Solids <br />Glycol Bulk 50/50 <br />Glycol Bulk Conc. <br />TSDF <br />Evergreen Oil, Inc. CFR <br />6880 Smith Ave. 33210 Western <br />Newark, CA 94560 Union City, CA 94587 <br />rAMRnRVA1R rAT nnnn41507 <br />TOTAL CHARGES <br />_- — <br />/ <br />Generator certifies that it has established a program to reduce the volume or <br />Source: ❑ Collection Station ® Government quantity & toxicity of the hazardous waste to the degree determined by <br />❑ Marine ® Agricultural ® Industrial generator to be economically practicable. <br />I hereby certify that I have read and have the authority to <br />bind the above the above listedgenerator to the terms on the reverse <br />the terms on the reverse <br />Retain Sample # 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 />closure 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 not these -more stringent requirements. This notification is for information purposes only. <br />