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vergreenvp~ e>� al Services <br /> dedicated to the t coon of the envtronntent2 <br /> To schedule a pickup, call Send payment to: <br /> 800-596-94ergreenil, Sales Order# J '^�j . - � � <br /> 55 <br /> 6880 Smith Ave.,Newark,CA EPA#CAD982413262 Dept LAO2323 c <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 Pasadena,CA 91185-3234 <br /> GENERATOR/JOB LOCATION BILLING INFORMATION Date: <br /> NA E. <br /> _i . NAME <br /> ADDRESS � CASH Q CHECK <br /> ADDRESS # <br /> '6z<;l, C S OMER ODE No. <br /> CITY STATE ZIP CO. CITY < <br /> STATE ZIP CO. PO# <br /> PHONE NO. PHONENO. n ~ t �Win, Fr- <br /> NO.NO. CUSTOMER EPA ID NO. <br /> � 7 <br /> PRODUCT WASTE MANIFEST <br /> CODE NUMBER QUANTITY UNITS PRICE AMOUNT <br /> Used oil,Non-RCRA Hazardous Lubricating CA22 <br /> •�'f' �� <br /> Waste,Liquid Industrial CA221 Gal. <br /> Used Automotive Antifreeze,Non•RCRA Haurdous Gal' <br /> Waste Li uid CA134 <br /> RQ Waste Combustible Liquid.N.O.S.NA Gal. <br /> 1993 Ill(Oil contaminated with halogens) CA221 <br /> Fos I�aoz Gal. <br /> Oil&Water,Non-RCRA Hazardous Waste Liquid CA223 <br /> Non Hazardous Water — Gal. <br /> Waste Solids and Sludges _ Gal. <br /> Wash Out Gal. <br /> Pressure Washer/Steam Cleaner Each <br /> Day <br /> Transportation <br /> Fuel Surcharge mss' <br /> Glycol Bulk 5 50/Specify Product <br /> Gal. <br /> Glycol Bu Conc./Specify Product <br /> Gal. <br /> TEST: Clor D Tech 4000 ppm Clor D Tech 1000 Pass <br /> Fail <br /> Retain Sample# Tot Char es <br /> Re ui><ed 7' C <br /> Field Service Work Description: <br /> Other: / <br /> Other: <br /> TS <br /> Consolidated Manifest D)hl VIER CHEC <br /> Evergreen Oil,Inc. Evergreen Oil,Inc.-DavisEvergreen oil,Inc.-Fresno <br /> 6880 Smith Ave. ❑ Road 30B ❑4139 N.Valentine ❑ Time In Time Out <br /> Newark,CA 94560 Davis,CA 95616 Fresno,CA 93722 ❑ Tank/Drum Properly Labeled <br /> CAD980887418 CAD982446874 CAD982446882 ❑ Accumulation Start Date Marked <br /> ❑ Evergreen Env.Svc. ❑ EvePeelMIM-Satualvfatia❑ ❑ House Keeping-Tank/Drum Clean <br /> Carson, <br /> S.San Pedro 745 a West Bett ravia9345 ❑ Other Services Checked: ❑ Oil, ❑ Filters/Drums, ❑Antifreeze <br /> Carson,CA 907 Santa Maria,CA 93454 <br /> CAD9816964Z CAD982446858 ❑ Called in other services needed ❑Oil, ❑ Filters/Drums, ❑Antifreeze <br /> Source: Collection Station ❑Government Generator certifies that it has established a program to reduce the volume or <br /> quantity&toxicity of the hazardous waste to the degree determines oy <br /> ❑Marine ❑ A ricultural g <br /> g ❑ Industrial generator to be economically practicable. <br /> I hereby certify that I have read and have the authoritj 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 required to meet those more stringent requirements,and some out-of-state facilities that process used oil also meet those requirements. <br /> T se nclude more stringent leak detection and prevention requirements,engineering certifications of tank integrity,and financial assurances for <br /> cl sur 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 /> no these more stringent relpirements.This notification is for information purposes only. <br /> �j, /2_%�-i i %�f <br /> D er Signature rint Name Route# Date ure Generator SignatPrint N me nate <br />