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,✓, N° 95438 <br /> Evergreen EnviOnmental Services <br /> ., Cothepi te(tiu Services <br /> dedicated to r4r proterrinJr nf7he anritanntent <br /> To schedule a pickup,call Send payment to: <br /> O Sates Order#�.mn��'�![5 <br /> 800-972-5284 Evergreen(Al,lnc. <br /> (88(1 Sm4hAvc Newark CA EPA#CAD9a2413162 Dept.LA 23234 - <br /> 1654n 8.San Perim St.,Carwtu.CA EPA#CAD4824I32n2 Fax.idena.CA 91185-3234 Date: <br /> GENERATORIJOB LOCATION BILLING INFORMATION <br /> NAME _ NAME CASH E]CHECK <br /> ADDRESS ADDRESS CUSTOMER CODE.NO. <br /> s- e7 __ <br /> Cfry - STATE ZIP CO. CITY .STATE ZIP CO. PO# <br /> j <br /> PHONE NO. PHON E NO. PROFILE.NO. CUSTOMER EPA B)NO. <br /> PRODUCT WASTE MANIFEST <br /> CODE NUMBER QUANTITY UNITS PRICE AMOUNT <br /> Waste latex Paint(Non-RCRA) <br /> Waste Latex Maim(Non-RCRA) <br /> Waste Paint Related(Flammables oil based) <br /> 'Ataste Paint Related(Flammables oil based) <br /> Waste Aerosols Cans <br /> op-A. AVlnmJwa N',wlp snW(,- 4 <br /> fkbr"r vtiunnnfi wLR ,rManm Erau¢ubdu <br /> txw.,IkMii <br /> Rw lu�rtNw W,Said h coman„n:,uxl wia� eiiWeuni R.,4ua,6om, <br /> Waste Corrosive Liquids,n.o.s. <br /> Waste Flammable Liquids,n.o.s. <br /> Waste Flammable Liquids,n.os. <br /> Non-RCRA Hazardous Waste,Liquid <br /> Non-RCRA Hazardous Waste,Liquid <br /> Waste Toxic Liquids in,Solids(Class 9) ...f7J <br /> Waste Oxidizing.Liquids or Solids <br /> Domed Used Oil Filters <br /> Empty Drums <br /> Non Hazardous Water <br /> Non Hazardous Water <br /> Nun Hazardous Solids <br /> Non Hazardous Solids <br /> Glycal Bulk 50150 <br /> Glycol Bui enc. <br /> TOTAL CHARGES <br /> TSDF <br /> Evergreen Gil,brc. SA Recycling <br /> 6880 Smith Ave. ® 33210 Westem ❑ <br /> Newark,CA FAf560 Union City,CA 94587 <br /> CAD980887418 CAL000344530 <br /> Source: ❑ Collection StationGCneralor Certifies that it has established a program to reduce the volume or <br /> ❑GoVermnent quantity&toxicity of the hazardous waste m the degree determined by <br /> ❑ Marine j Agricultural ❑ Industrial generator to be economically practicable. <br /> I hereby certify that [have read and have the{lLttlurri <br /> Retain sarn le bind the above lia(gd,generafor to the terms o!3_Lb gevcrse <br /> p aide of this form <br /> IMPORTANT NOTICE REGARDING THE DISPOSITION OF YOUR OIL. <br /> Per California Health and Safety Code Section 25250,9,Evergreen hereby advise%customer that customers 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 /> T!!-----ROtHe <br /> , 'agent requirements applicable to hazardous waste management facilities.California facilities that handle or process used <br /> d to ineet it ise more stringent.requirements,and some out-vf--state facilities that process used oil also meet those requirement's. <br /> Thee more strin ent leak detection and revention requirements,engineering certifications of tank.integrity,and financial assurances for <br /> ccidental r leases. ' rid used oil to out-of-state facilities that comply only with federal used oil management standards <br /> more sir r,- Ire s:This,notification is for information purposes only. <br /> gnature Print Name Route# Date Generator's Signature Print Name Date <br />