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Evergreen Envirqgknental Services ® {I _ ® tva t.i ^+..."� '-.s •.y•v ice, . dWA edicated to to the pi-otcr on n/the cnrirnnnrem To schedule a pickup, call Send payment to: Sales Order #i. a 800-596-9455 Bergreen Oil, Inc. 6SS0 Smith A� c.. Ne��'ark. CA EPA# CAD982413262 Dept. LA 23234 16540 S. Stun Pedro SI.. Carson. CA EPA# CAD982413_62 Pasadena, CA 91185-3234 Date: 'r.>\r17nArr"V/1nre I nnATT"N RH 1I IN('- INFORMATION NAME NAME CASH ❑ CHECK ❑ # ADDRESS ADDRESS CUSTOMER CODE NO. CITY STATE Z111 CO. CITY STATE ZIP CO. PO # PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. PRODUCT .WASTE WASTE MANIFEST NUMBER QUANTITY UNITS PRICE ANLOUNT -- '1 Used oil. Non-RCRA Hnzardous Lubricating CA221 Cal. Waste. Liquid ladustrial CA221 Gal. t7,d.AmI— Anol....�. s„„-RCRA IL --k— CA 134 Gal. RQ Al adc Cnni1—I&I, hquiJ. N.OS. NA i 0i l amtnminnn•d �� i�h haloscn s CA221 Fool/1`002 Gal. _[99311 Oil & Water. Non-RCRA Hazardous Waste Liquid CA223 Gal. Non Hazardous Water Gat. Waste Solids and Sludges Gal. Wash Out Pressure Washer'/Steam Cleaner rHi Transportation Fuel Surcharge� 31ticol Bulk 50/50/Specify Product Gal. Glycol Bulk Conc./Specity Product Gal. TEST: ❑ Cl or D Tech 4000 - - ppm ❑ Clor D Tech 1000 ❑ Pass ❑ Fail'' ; Retain Sample #: Required .4 TotalCharges Field Service Work Description: Other: i` Other: TSDF 0 Consolidated Manifest ❑Evergreen Oil.. Inc. ❑ Evergreen Oil, Inc. - Dacis ❑ Evergreen Oil, Inc. - Fresno 6880 Smith Ave. Road 30B 4139'N. Valentine Newark. CA 94560 Davis, CA 95616 Fresno. CA 93722 CAD980887418 CAD982446874 CAD982446882 DRIVER CHECKLIST Timc In Time Out Tank/Drum Properly Labeled Accumulation Start Date Marked ❑ ENeigreen Env. Ssc. 1:1Eco'm_eenOil,Inc.-Sattta!staria❑ u House Kccpin2 -Tana Dum rC.tn 16604 S. San Pedro 745 A West ____.avia ❑ Other Sercrces Checked: ❑ Oil. ❑ Fdtel:',/DrUnts. ❑ Antifreeze Carson. CA 90746 Santa Maria, CA 93454 CAD981696420 CAD982446858 [1 Called in other services needed [j Oil. ❑rruE]Filtes/Dms. Antifreeze Generator certifies that it has established a program to reduce the Volume or Source_: ❑ Collection Station ❑ GOVertiment quantity & toxicity of the hazardous waste to the degree determined by ❑ Marine ❑ Aat7cultural L)Indushlal generator to be economically practicable. I hereby certify that I have read and have the authority 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 ,oly with the more stringent requirements applicable to hazardous waste management facilities. California facilities that handle or process used e required to meet those more stringent requirements, and some out-of-state facilities that process used oil also meet those requirements. .,e include more stringent leak detection and prevention requirements, engineering certifications of tank integrity.. and financial assurances for closure and accidental releases. It is lawful to send used oil to out-of-state facilities that comply only vVith federal used oil management standards and not these more stringent requirements. This notification is for information purposes only. Driver Signature Print Name Route # Date Generator's Signature Print Name Date