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A WORK ORDEK/SERVIUE: ACTKEF,'MhN'1' <br />Evergreen Environmental Services N° 381419 <br />dedicated to the protection of the environment <br />To schedule a pickup, call Send payment to: Sales (7Tt1# <br />er <br />800-596-9465 Evergreen Oil, Inc. <br />6850 Smith Ave.; Newark, CA EPA$ OAD982413262 P.O. BOX 30517 ,fJ <br />18640 S. San Psdro St., Carson, CA EPA* CAD9e241a2a2 Los Angeles, CA 90030-0517 Date: v <br />GENERATORIJOB LOCATION BILLING INFORMATION <br />ac.:. <br />NA <br />NAME <br />CASH ❑ CHECK ❑ <br />AD SL <br />All <br />ADDRESS <br />I:I�ST CQ NO. <br />tf L <br />5 D? CO. <br />CITY <br />STATE LIP <br />CO. <br />PO M <br />PHOJE / <br />PHONE NO. <br />PROMS NO, <br />CUSTOMEREPA 1D NO. <br />PRODUCT <br />WASTE <br />CODE <br />MANIFEST <br />NUMBER <br />QUANTITY UNITS <br />PRICE AMOUNT <br />Used oil, Non-RCRA Hazardous Lubricating <br />CA221 <br />Gal. <br />Waste, Liquid Industrial <br />CA -121 <br />Gal. <br />Uea AuOm Odl A.1if—i N—RCRA R-6— <br />w„t, Li aid <br />CA134 <br />Gat. <br />R11. �sce CaetnuuGk tJquid, N.p.x. xA <br />CA221 ltm)2 <br />Gal- <br />ial.til <br />Oil& Water, Non-RCRA Hazardous Waste Liquid <br />CA221 <br />Gal. <br />waste Solids and Sludges <br />Gal. <br />Wash Out <br />Each <br />Drained uaed Oil Filters <br />Drum <br />Non-RCRA H Solids (pity debt s) <br />CA223 <br />Drum <br />%mpty 17ntrtts , �.,t `• <br />Drum <br />Eta �r'- <br />Hirs, <br />f, <br />h: <br />Water <br />cal. <br />k 5(1!50 <br />Gal. <br />G(ycol Bulk Conc. <br />Gal, <br />TEST:( Ctgr D Tech 40M pm ❑ Clor 1 Tech 1000 ❑ Pass FailHalogen <br />DettctorlFlamc Test <br />ass ❑ Fail <br />k <br />Field Service Wurk Desenption: <br />]Oral C&ges <br />h <br />Other: <br />Other: <br />Vacuum Services'nme <br />Out of Yard On Site <br />TSDF <br />Everyzew Oil, Inc, <br />u tiRRO Stnith Ave. <br />Newark, CA 94560 <br />CA O8B7418 <br />Site Off Load Start Oft' Load End Return to Yard <br />Consolidated Manifest <br />Evergreen Env. Svc. Evcrgrcon Env. Svc. AJS Filter <br />Road 308 L 4139 N, Valentine 1:115131 Clark Ave. <br />Davis, CA 95616 Fresno, CA 93722 Industry, CA 91745 <br />D98 .. CAD98:44(/814 CAD9824468$2 CAJ^AAV97432 <br />QEvergreen Env, Svc Ever n Env. Svc. C� C1 A U Greenleaf line, Svc. <br />16604 S. San Pe 745 West Beneravia 944 E. Slauson Ave. 33210 West. LJ 3474 Toon Circic <br />Carson, CA Santa Maria, CA 93454 rays Angeles, CA 90011 Union City, CA 94597 valleyy 9pn ngs, CA 95352 <br />CAD9816 0 CAD982446858 CAL000110021 CALOM1507 CALfM7f12I4411 <br />Source: Collection Station D Government Genentor certifies that it has established a program to reduce the volume or <br />quantity & toxicity of the hazardous waste to the degree detertnined by <br />❑ Marine ❑ Agricultural ❑ Industrial generawr to be economically practicable, <br />I hereby certify th$t I have read and have the authority to <br />Wind the above listed generator to the terms; on the reverse <br />Retain sample—.. side of this form. <br />IMPORTANT NOTICE REGARDING THE DISPOSITION OF YOUR OIL. <br />Per Callfornia 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. v_sed <br />oil are required to meet those more stringent requirements, and some out-of-state facilities that process used oil also meet those rtxluircmcnts. <br />These include more stringent Icak detection and prcvcntion requirements, engineering certifications of tank integrity, and financial assurances for <br />closure and accidental releases- Tt is lawful to send used ail to out-of-state facilities that comply only with federal usc6 oil management standards <br />and not these m c stringent requirements. This notification is for information purposes only. <br />