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01/29/2013 16:53 FAX 12094658060 BULKSTOCKTON@BULK-DTI.CO Z0008/0008 <br /> .I � <br /> AEvergreen Envierltal Service' s' N-0 _6W�_.__�j_ <br /> dedicated to the protection of the environment " <br /> To schedule a pickup,call Send payment to: Sales Order J1 11d:, <br /> 800-972-5284v <br /> E ergreen 011,Inc. <br /> 6880 Smith Ave.,Newark,CA EPA#CAD982413262 o Dept.LA 23234 <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 Pasadena,CA 91185-3234 Date: '-�-$��I _ <br /> GENERATOR/JOB LOCATION BILLING INFORMATION <br /> N E NAME CASH CHECK <br /> # _ <br /> ADDRESS ADDRESS C 'STOMER CODE NO. <br /> 3 <br /> CITY11 STATE ZIP CO. CITY STATE ZIP CO. P # <br /> 44 9l &. _ <br /> PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. <br /> WASTE MANIFEST <br /> PRODUCT CODE NUMBER QUANTITY UNITS PRICE AMOUNT <br /> Used oil,Non-RCRA Hazardous Lubricating CA-22 L (yid I-' Gal. <br /> Waste,Liquid Industrial CA221 Gal. <br /> Used Automotive Antif=ze,Non-RCRA Hazardous CA134 - Gal. t.+ <br /> Waste Li id t <br /> RQ WaAc Combustible Ugnid,N.O.S.NA CA221 Gal. S <br /> 1993 In(Oil contaminated Wlth halo ens) MIFW2 SI <br /> Oil&Water,Non-RCRA Hazardous Waste Liquid CA223 Gal. <br /> Non Hazardous Ware, Gal. <br /> Waste Solids and Sludges Gal. <br /> Wash Out Each <br /> Pressure Washer/Steam Cleaner Day <br /> Transportation Hrs. a <br /> Fuel Surcharge % <br /> Glycol Bulk 50 JSpecify Product Gal. <br /> Glycol Bul onc./Specify Product Gal. <br /> TEST:izClor D Tech 4000.1--k--ppm []Clor D Tech I000 Pass ❑Fail <br /> Retain sample# Total Charges <br /> V . Re :red 7 C,3 <br /> Field Service Work Description: <br /> f Other: <br /> Other: <br /> ,s <br /> TS' Consolidated Manifest DRIVER C <br /> i Evergreen Oil,Inc. ❑ Evergreen Oil,Inc.-Davis Evergreen Oil,inc.-Fresno ❑ 'Time In Time Out <br /> t 688D Smith Ave. Road 3DB 4139 N:Valentine <br /> Newark,CA 94560 Davis,CA 95616 Fresno,CA 93722 G Tank/Drum Properly Labeled <br /> CAD980887418 CAD982446874 CAD982446882 Cl Accumulation Start Date Marked <br /> E] Evergreen Env.Svc. n Ex�tOil,lir.-Santa Maria❑ ❑ House Keeping-Tank/Drum Clean <br /> 16604 S.San Pedro LJ 745 A West Beueravia <br /> Carson,CA 907 Santa Maria,CA 93454 ElOther_Services Checked: Oil, ❑.FiItetslDiums, ❑Antifreeze <br /> CAD9816964 CAD982446858 10 Called in other services needed[I Oil, 0 Filters/Drums,o Antifreeze <br /> Generator certifies that it has established a program to reduce the volume or <br /> Source: Collection Station CJ 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 pnd have the ftuthority to <br /> bind the above listed generatoEto the leans on the reverse <br /> 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 p <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 /> °r closer nd 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 n these more stringent requirements.This notification is for information purposes only. <br /> 1. <br /> { � 7 <br /> i <br /> D#Jr Signature 11Mpt Name Route# Date Ge r! r s Signature Print Name Date <br />