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.-. --- .,,r.-...-r, ---- - --- 13d1Gh VtLLGt tt 800-972-52P A Evergreen Oil,Inc. 6880 Smith Ave.,Newark,CA EPA#CAD9824 t. 2 Dept.LA 23234 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 Pasadena,CA 91185-3234 Date: GENERATORIJOB LOCATION BILLING INFORMATION NA NAME CASH❑CHECK❑ Ilboel&_ L6451:e # 'nDkESS — ADDRESS CUSTOMER CODE NO. 111J fl CITY STATE ZIP CO. CITY STATE ZIP Co. PO# 13FIONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT CODE NUMBER Used oil,Non-RCRA Hazardous Lubricating CA2RA9=a&TdMe Gal. Waste,Liquid Industrial CA221 Gal. Used Automai-An6f=ze.Non-RCRAHa=dous CA134 Gal. Waste Li uid RQ Waste Combustible Liquid.N.O.S.NA CA221 Gal. 1993 tel(Oil contaminated with halo ens) F001/F002 Oil&Water,Non-RCRA Hazardous Waste Liquid CA223 Gal. Non Hazardous Water Gal. vtj Waste Solids and Sludges Gal. Wash Out Each Pressure Washer/Steam Cleaner Day Transportation Hrs. Fuel Surcharge % PEI WFPSE"Cp"� Glycol Bulk 50/5 pecify Product Gal. Glycol Bulk ncJSpecify Pro��d__``uct Gal. TEST: Clor D Tech 4000sappm ❑Clor D Tech 1000 : Pass ❑Fail Retain sample# Total Ch s Required 8 _ Field Service Work Description: Other: Other: TSDF Consolidated Manifest DRIVER C ISZ` E4Evergreen Oil,Inc. E] EvergreenOil,Inc.-Davis❑ Evergreen Oil,Inc.-Fresno ❑Time Ii Time Out 880 Smith Ave. Road 30B 4139 N.Valentine Newark,CA 94560 Davis,CA 95616 Fresno,CA 93722 ❑Tank/Drum Properly Labeled CAD980887418 CAD982446874 CAD982446882 ❑ Accumulation Start Date Marked ❑ Evergreen Env.Svc. ❑ Eraglaen0il,trc.-S=N1ara❑ ❑ House Keeping-Tank/Drum Clean 16604 S.San Pedro 745 A West Betteravia ❑ Other Services Checked: ❑Oil, ❑ Filters/Drums, ❑Antifreeze Carson,CA 90746 Santa Maria,CA93454 CAD981696420 CAD982446858 ❑ Called in other services needed ❑Oil, ❑ Filtem0rums,❑Antifreeze Generator certifies that it has established a program to reduce the volume or Source: Collection Station ❑Government quantity&toxicity of the hazardous waste to the degree determined by ❑Marine ❑ Agricultural ❑ Industrial generator to be economically practicable. I hereby certify that I have read and have the authority to bind the above listed generator to the terms on the reverse side of this form. IMPORTANT NOTICE REGARDING THE DISPOSITION OF YOUR OIL. Per California Health and Safety Code Section 25250.9,Evergreen hereby advises customer that customer's shipment of used oil may be transported to a facility that is required to comply with federal regulations applicable to management of used oil,but that is not required to comply with the more stringent requirements applicable to hazardous waste management facilities.California facilities that handle or process used oil are required to meet those more stringent requirements,and some out-of-state facilities that process used oil also meet those requirements. These include more stringent leak detection and prevention requirements,engineering certifications of tank integrity,and financial assurances for 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 and t these more stringent requirements.This notification is for information purposes only. 44 river Signature Print Name Route# Date Generator's Signature Print Name Date White Copy=Customer Copy-Pink&Yellow Copy--Office Use-Gre Copy=Attach to manifest-Golden Copy--Driver Copy