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c <br />J <br />✓^ <br />j Evergreen Envi4bmental Services <br />Coepro dServices dedicated m the pmfection of the environment <br />To schedule a pickup, call Send payment to: <br />800-596-9455 Evergreen Oil, Inc. <br />6880 Smith Ave., Newark, CA EPA# CAD982413262 P.O. BOX 30217 <br />16540 S. San Pedro St., Carson, CA EPA# CAD982413262 Los Angeles, CA 90030-0517 <br />GENERATOIj/JOB LOCATION BILLING INFORMATION <br />�� <br />�� 77 i <br />N° 4588 6 <br />Salk rae �' <br />Date/ <br />24�,o <br />NAME T <br />NAME <br />CAS C <br /># D <br />SS <br />E <br />S AT ?Z <br />CO. <br />CITY <br />STATE ZIP CO. <br />PO# <br />PH ENO. <br />PHONE NO. <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />PRODUCT <br />WASTE <br />CODE <br />MANIFEST <br />NUMBER <br />QUANTITY UNITS PRICE AMOUNT <br />Waste Latex Paint (Non-RCRA) <br />Waste Latex Paint (Non-RCRA) <br />Waste Paint Related (Flammables oil haled) <br />Waste Paint Related (Flammables oil based) <br />Waste Aerosols Cans <br />Non-RCRAHuz douswu¢Snlid iSoil, <br />Debris conumina¢d with uoleum. bdmcarbonq <br />Nan-RCRA 11 z,dous Wac¢. Solid(Soil. <br />Debris mnlaminaiul wirM1 agleam h dmrnrbom <br />Waste Corrosive Liquids, n.o.s. <br />Waste Flammable Liquids, n.o.s. <br />Waste Flammable Liquids, n.o.s. <br />Non-RCRA Hazardous Waste, Liquid <br />Non-RCRA Hazardous Waste, Liquid <br />Waste Toxic Liquids or Solids (Class <br />Waste Oxidizing Liquids or Soli <br />/ <br />Drained Used Oil Filters <br />Empty Drams <br />Non Hazardous Water <br />Non Hazardous Water <br />Non Hazardous Soli <br />Non Hazardous Soli s <br />Glycol Bulk 50/50 <br />Glycol Bulk Cone. <br />TSDF <br />❑Evergreen Oil, Inc. CFR <br />6880 Smith Ave. 13210 Western ❑ <br />Newark, CA 9456 Union City, CA 94587 <br />CAD980887418 CAL000091507 <br />TOTAL CHARGES <br />r <br />Generator certifies that it has established a program to reduce the volume or <br />Source: ❑ Collection Station ❑ Government 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 I have read and have the authority to <br />hind 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 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 are required to meet those more stringent requirements, and some out-of-state facilities that process used oil also meet those requirements. <br />These include more stringent leak detection and prevention requirements, engineering certifications of tank integrity, and financial assurances for <br />closure 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 />and not these more stn em requirem nts. This notification is r mfg anon purposes only. 1 % m�,1� <br />Driver S9 ame Route # Date Crenerator's Signature Print Name Date <br />