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FROM (FRI)JUL 27 2012 1e: 1e/ST. 16: 17/Ho.751S884114 P 5 <br /> -,%i rrvl�l� vl�l� lt�.�ll..�rii�l��rlvlyd�1 <br /> J Evergreen EnvirSirnental Services No 6 3 714 <br /> dedicated to the protection of the environmew <br /> To schedule a pickup, call Senda ment to: <br /> � Y SalesOrder <br /> 800-972-5284 Evergreen Oil,Inc. <br /> 6880 Smith Ave..Newark,CA EPA#CAD982413262 Dept.LA 23234 <br /> 16540 S.San Pedro St..Carson,CA EPA#CAD982413262 Pasadena,CA 91185-3234 Date:?� <br /> GENERATOR/JOB LOCATION BILLING INFORMATION <br /> NA NAME <br /> r CASA Q CHECK[] <br /> v7 # <br /> ADDRESS ADDRESS CUSTOMER COME NO. <br /> CITYSTATE' <br /> TA ZIP CITY STATE ZIP CO. PO# <br /> P90NE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. <br /> T1_570i5z) ( ) <br /> PRODUCT WASTE MANIFEST <br /> CODE NUMBER QUANTITY UNITS PRICE AMOUNT <br /> Used oil,Non-RCRA Hazardous Lubricating CA22 -T Q Gal, <br /> Waste,Liquid Industrial CA221 Gal. <br /> Used.I It 1i-AMifrt .Non-RCRA Huadws CA 134 <br /> waste Li uid Gal. <br /> Rq W.,C—b,.ubk Liquid.N.O.S.NA CA221 Gal <br /> On <br /> 1993 in cmtatuineted with halo ens) FMIIFpn2 <br /> Oil&Water,Non-RCRA Hazardous Waste Liquid CAI-23 tial. <br /> Non Hazardous Water Gal. <br /> Waste Solids and Sludges Gal. <br /> Wash Out Each <br /> Pressure Washer/Steam Cleaner Day <br /> Transportation Firs. <br /> Fuel Surcharge % <br /> Glycol Bulk 50/ Specify Product Gal. <br /> Glycol Bulk oncdSpecify Produuct�� _ Gal. <br /> TEST: Clor D Tech 4 NZ , .tppm Clor D Tech 1000 Pass L]Fail <br /> Retain sample# Total Charges <br /> Re uired <br /> Field Service Work Description: <br /> Other: <br /> Other <br /> ��Fv.vIQ,�, <br /> Consolidated Manifest D R CHECKLIST <br /> Oil,Inc. ❑ Ev.V.Oil,Inc.-Davis 0 Evergreen Oil,Inc.-Fresno ❑ Time In Ttme <br /> mith Ave. Road 30B 4139 N.Valentine <br /> k,CA 94560 Davis,CA 95616 Fresno,CA 93722 ❑ Tank/Dn Properly Labeled <br /> AD980887419 AD982446874 CAD982446882 ❑ Accumulation Start Date Marked <br /> Evergreen Env.Svc. Et�geat(alirc-SarttA9ao� ❑ House Keeping-Tank/Drum Clean <br /> 16604 S.San Pedro 745 A West Betteravia ❑ Other Services Checked: ❑Oil, ❑ Filters/Drums, ❑Antifreeze <br /> Carson,CA 907 Santa Maria.CA 93454 <br /> CAD9816964 CAD982446858 I❑ Called in other services needed ❑Oil, ❑ Filters/Drums, Antifreeze <br /> Source: Collection Station ❑Government Generator certifies that it has established a program to reduce the volume or <br /> quantity&toxicity of the hazardous waste to the degree determined by <br /> ❑Marine ❑ Agricultural ❑ Industtial generator to be economically practicable. <br /> — I hereby cert'y that I have read and have the authority to <br /> bind the above listed izenerator 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 at is not required to <br /> comply wi the more stringent requirements applicable to hazardous waste management facilities.California faciliti s that handle or process used <br /> oil are r red to meet those more stringent requirements,and some out facilities that process ess used oil also et those requiremen[s- <br /> These in de more stringent Irak tection and prevention requirements,engineering certifications of tank integrit d financial assurances for <br /> closure d accidental releases.I s lawful to send used oil to out <br /> facilities that comply only with federal u oil management standards <br /> and no ese more stringent r irements.This notification is for information purposes o v. <br /> A 1-44ver Signature 'nt Name Route# Date Ge tor's Signatu t Name Date <br /> nu................. ... c..i.+...,r`,...,, .,,...r....,, <br />