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•1065W lu but ICUUIC cl I IUKUP, U&II L3ullu Paytuclat tv. <br /> Dales Urtler� <br /> 800-596-94r^ Evergreen Oil,Inc. <br /> 6880 Smith Ave.,Newark,CA EPA#CAD9824i—o2 Dept.LA 23234 <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAM82413262 Pasadena,CA 91185-3234 Date:9-, +, <br /> GENERATORIJOB LOCATION BILLING INFORMATION <br /> N NAME CASH❑CHECK01 <br /> ❑ <br /> # <br /> ADDRESS ADDRESS CUSTOMER CODE NO. <br /> l� <br /> s•rATE ZIP CO. CITY STATE ZIP CO. PO# <br /> W 2-17— <br /> PHONE <br /> - ZPHONE NO. PHONE NO. PROFILE NO. CUSyTOMER EPJJA ID NO. <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> Used oil,Non-RCRA Hazardous Lubricating CA22 Gal.. <br /> Waste,Liquid Industrial CA221 Gal. <br /> U.ud Automtaive Antifreeze,Non-RCRA Hazardous CA 134 Gal. <br /> Wase Li uid <br /> RQ Waste Combustible Liquid.N.O.S.NA CA221 Gal. <br /> 1993 m(oil mntamina2 with holo ens F001/F002 <br /> Oil&Water,Non-RCRA Hazardous Waste Liquid CA223 Gal. <br /> Non Hazardous Water Gal. <br /> Waste Solids and Sludges Gal. <br /> Wash Out Each <br /> Pressure Washer/Steam Cleaner Day 1 <br /> Transportation His. <br /> Fuel Surcharge % <br /> Glycol Bulk 5990/Specify Product Gal. <br /> Glycol Bul onc./Specify Product Gal. <br /> TEST:VClor D Tech 4000-46=1ppm ❑Clor D Tech 1000❑Pass❑FailPass ❑Fail <br /> Retain sample#/ Total Charges <br /> Re uired / <br /> Field Service Work Description: <br /> Other: <br /> Other: <br /> TS Consolidated Manifest D HECKLIST <br /> Evergreen Oil,Inc. ❑ Evergreen Oil,Im.-Davis[:] Evergreen Oil,Inc--Fresno ❑ Time InTime Out <br /> 6880 Smith Ave. Road 30B 4139 N.Valentine <br /> Newark,CA 94560 Davis,CA 95616 Fresno,CA 93722 ❑Tank/Drum Properly Labeled <br /> CAD980887418 CAD982446874 CAD982446882 ❑ Accumulation Start Date Marked <br /> ❑ Evergreen Env.Svc. ❑ Evapeen0klrr--Sa=Matia0 ❑ House Keeping-Tank/Drum Clean <br /> 16604 S.San Pedro 745 A West Betteravia ❑ Other Services Checked:❑Oil, ❑ Filters/Drums, ❑Antifreeze <br /> Carson,CA 90746 Santa Maria,CA 93454 ❑ Called in other services needed ❑Oil, ❑ Filters/Drums,❑Antifreeze <br /> CAD9816964X CAD982446858 <br /> Generator certifies that it has established a program to reduce the volume or <br /> Source: Collection Station L)Government quantity&toxicity of the hazardous waste to the degree determined by <br /> ❑Marine ❑ Agricultural ❑ Industrial generator to be economically practicable. <br /> I herebycertify that I have read and have the authority to <br /> bind the above listed generator to the terms 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 <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 /> closur d 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 t hese more stringent requirements.This notification is for information purposes only. <br /> ver Signature Print Name Route# Date Generator's Signature Print Name Date <br /> White Copy=Customer Copy-Pink&Yellow Copy=Office Use-Green Copy=Attach to manifest-Golden Copy=Driver Copy <br />