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Evergreen Environmental Services <br /> dedicated to Me protection of the environnienl <br /> To schedule a pickup, call <br /> � <br /> 800-972-5284 Evergreen Oil, Inc. Sales Order #=J _ <br /> 6880 Smith Ave.. Newark.CA EPA#CAD982413262 P.O. BOX 678252 <br /> 16540 S.San Pedro St..Carson, CA EPA#CAD982413262 Dallas. TX 75267-8252 Date. <br /> GENERATOR/JOB LOCATION BILLING INFORMATION <br /> NAME NAME CASH[] CHECK <br /> ADDRESS ADDRESS CUSTOMER CODE NO'.- <br /> CITY ...... .. <br /> STATE <br /> O.CITYSTATE ZIP CO. CITY STATE ZIP CO. PO# <br /> PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO 'y <br /> A �; w <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> Used oil, Non-RCRA Hazardous Lubricating CA221 _ it = - Gal - _ •t <br /> Waste.Liquid Industrial CA221 Gal. , » <br /> ¢.�Amom, Aartr,c.c_Noo-RCRA H,omlor, CA 134 <br /> wmsc wall' - - Gal. <br /> RQN cC,nb 1] Cy Itl.NCis NA CA221 <br /> 19)t at Oil co L J widi LaW2nn1 FWVPoW Gal. <br /> Oil &Water.Yon RCRA Hazardous Waste Liquid CA221 Gal. v' <br /> Waste Solids and Sludges Gal. = �- <br /> Wash Out <br /> Each <br /> Drained Used Oil Filters pwm l <br /> Non-RCRA Hazardous Waste Solids(oily debris) CA223 Drum <br /> Empty Drums Drum <br /> Transportation Hrs. <br /> Non Haza9fous Water r-{ Gal. . <br /> TEST: Clor D Tech 4000—ppm ❑Cher D Tech 1000 u Pass Q Fail Q Halogen Detector/Flame Test ❑Pass ❑Fail _ -- <br /> Field Service Work Description: <br /> Other <br /> Other: <br /> Vacuum Services Time <br /> Out of and On Site Off Site_Off load StartOff Load End—Return to Yard <br /> TSPF Consolidated Manifest <br /> Evergreen Oil,Inc. ❑ Evergrtxn Env.Svc. ❑ Evergreen Env.Svc. ❑ AJS Filter ❑ <br /> 6880 Smith Ave. Road 30B 4139 N.Valentine 15131 Clark Ave. <br /> Newark,CA 94560 Davis,CA 95926 Fresno,CA 93711 -Industry,CA 91745 <br /> CAD980887418 CAD982446874 CAD982446882 CAD000097432 <br /> ❑ Evergreen Env.Spc. Evergreen Env.Svc. ❑ CFR ❑ CFR Greenleaf Env.Svc. <br /> 16604 S.San Pedro 745 A West Beneravia 944 E.Slauson Ave. 33210 Western 3474 Tryon Circle <br /> Carson,CA 90146 Santa Marta,CA 93454 Los Angeles,CA 90011 Union City,CA 94587 ValleSprings,CA 95352 <br /> CAD98169 CAD982446858 CAL000110021 CAL000091507 CA-9214411 <br /> $OUICe: COIICCtIOn Station ❑Government Generator certifies that it has established a program to induce the volume or <br /> 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 1 have read and have the authority to <br /> �' bind the above Usted generator to the terms on the reverse <br /> Retain sample # side of this form. <br /> Y4"i 4 <br /> Driver-Signature Print Name Route# Date -Generator's Signature Print Name Date <br />