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2011-Feb-11 02:10 PM DSW AG 209-319-9967 15%42
<br /> WORK URDE 'KV1C;E AUltEk;MEN7'
<br /> Evergreen Environmental Serviceso
<br /> To ," "' ', •7 -,
<br /> ••'� elerlircried to 1�lv pry),fectforl of the eavirnarnerrr ��,'•O //.'.
<br /> schedule pickup, call ticnd p,t}tocol tut SaIeStrrr d�'�
<br /> 800-59 -9455 Evergreen Oil, Inc.
<br /> 6a80 Smith Ave„Nowailt,CA EPA# 0982413262 P.U, BOX 30517
<br /> 19640 3,Sen Pearo 51•,Garcon,CA PA#CAD992413262 Los Angeles, CA 90030-0517 Date:
<br /> GENERATOWJOI3 LOCATION BILLING 1>1FORMA11ON
<br /> NAMF. CASH❑ CHECK�]
<br /> ADtiRE � T f11 .R C
<br /> /
<br /> CITY ST P CO. CI � / A F? iP /CC), Po#
<br /> PITON NO- PHONF NO, PROFILE O. C'U5T(IM1IF.R b:!'.A IU NO.
<br /> ( /
<br /> PRODUCT WASTE MANIFFRT QUANTITY
<br /> CODE NUMBER UNITS PRICE AMOUNT
<br /> ll.ptl oil,Nun-ItCRA Hiu,,udnus Lu,rlcatingj CA221 Gal,
<br /> Waste, Liquid Ind slriiil CA221 Grtl.
<br /> IJ u-d Aummmi a A-Fn v.N.-RCRA Irn:�inL.n- CA 133
<br /> Gal.
<br /> Ko w„,��c,,,,,Mwlnm I•I�mu.N ns.wY CA �- Gal,
<br /> W+ U111'Of116111t�Ylc w 'r, IIYI I{Mll/ti Y1�
<br /> nit&Water,Nun-RCRA Hazord,ws Wusr.(.iyui(l CA221 Out,
<br /> Wasle Solids and Slttdgo Gal,
<br /> wash Out Each
<br /> Drained Uscd Oil Filters Drum
<br /> Non-RCRA Hazardous Wus10 Solids(ofly d•hris) CA223 Drum
<br /> Vinilly Drums Drum
<br /> Transpurlmion His•
<br /> Non Huzdnlous Wcucr Out,
<br /> Glycol Balk 511/50
<br /> Gal,
<br /> Glycul Bulk Conc. - -- Gal.
<br /> TEST:❑ Clur t)Tcch 4(IO(h4prn Clor D'recti 1000 LI pass❑Fait Flutogen DetectoriFlarnc Test []P.,, ❑ Fall
<br /> field•9crricr Wort. M-wripllon: -1 oml Clwrak.'s
<br /> Other:
<br /> Other: _
<br /> Vnruum SorvicvK Time
<br /> Ottt of!'urd On Site G She, Otf Load Stott Orf Loud End Return to Yurd
<br /> TSDF ❑ Consolidated Manifest
<br /> f`1 Evergncn Oil.hic• f— 1'vcrgrven :nv,Svc. n tivorgreen Env.Svc, ❑ AIS Filler ❑
<br /> l_J 6881)Sinid1 Avc, l_I Rnnd oil a 4139 N. Valentine 15171 Clark Ava•
<br /> Nelvurk,CA 94560 Davis,CA 95616 Frvsno,CA 93722 Indl.117ry CA 91135
<br /> CAD9x089741ii CAI)9824-4A874 CAD982446M2 C.4UINAN197432 --
<br /> ❑ Pvcrgrcen Ni .Sac. ❑ 1?vcrgrcc t Env.Svc, n CFR CFR ❑ Grxnleal'Env.Svc,
<br /> IhM)4 S.Sw1 Pedro 755 A W'cs Betler[rvia l J y,ti F. Slauccnt Avc 1321q Wcnlcm 3474 Tuyon Ci%Ic
<br /> Carson,CA 90746 Sama Mart,CA 93454 Los Artgtiles.CA )I (Inion Cityy.CA 9-1587 Vallcv S�lrings,CA 95)52
<br /> CAW9169642f1 CADdR2 a5ri CAP)() 1 IM21 CAU100091107 CAIJI(X)-1341 t
<br /> Generator certifies dlar it hus csluhli.shed u progr in lo rucluce the volume or
<br /> $Gurce: U Collection Station 0 Government quantity&toxicity of the hwardous waste In the deltree determined by
<br /> U
<br /> U Marine Agricultural ❑ industrial gencrtuor to he worlomically pructicahle.
<br /> I hereby certify that I have read and have the authority to
<br /> bind the above listed generator to the terms an the reverse
<br /> Retain sample # side aP this form.
<br /> IMPORTANT NOTICE, REGARDING THE DISPOSITION OF YOUR OIL.
<br /> Per California Heultis and Surety Cade ection 25250.9, Nvergnxn hereby adviscs customer that (;ustomer's shipment of used oil may he
<br /> transported to it Iacility that in rcyuired t -o'
<br /> n31 with fcdcnif regulations applicable to munage[nent of used oil, but d)(11 is oat required tit
<br /> c)tnllly with the more stringent regt.rireme 1c apphcahle to hazardous waste nlnnagement fileilitics. California facilities that hiutdle or process u,scd
<br /> Oil arcrcyyaired In nisei those mare.slrin_ nt rCyuiruments. and some out-of-state kwilities that procem used oil also sleet those requircitients.
<br /> Thesc include ❑lure sn'Ingem Irak dclecllo and prevention requirements, ellgineering certifications of tank integrity. and fluncial assurtlnces for
<br /> rlusuty and accidental n:lewcs. 11 is tit”Fu lit send used oil to out of state I'acilities that comply only with fcrlerrll used oil management standards
<br /> and not these more slringcia rrquirtinients. 111is notilicttti(in N fur h1lornuuion purposes only.
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