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�.. RK 19SIE f E' A L <br />Evergreen Environmental Services No 169791 <br />dedicated to the protection of the environment <br />To schedule a pickup, Call _. Send -payment -to: - - - Sales Order # <br />800-972-5284 Evergreen Oil, Inc. <br />6880 Smith Ave.; Newark, CA EPA# CAD982413262 P.O. BOX 678252 <br />16540 S. San Pedro St., Carson, CA EPA# CAD982413262 Dallas, TX 75267-8252 - Date: <br />GENERATORLTOW LOCATION IBILLING INFORMATION <br />N <br />- <br />MANIFEST QUANTITY <br />NUMBER <br />NAME <br />_ <br />CASH ❑ CHECK ❑ <br />Z <br />✓1 <br />Waste, Liquid Industrial <br />CA221 <br />Road 30B <br /># <br />ADDRESS <br />CA134 <br />ADDRESS <br />RQ Waste Combusnble Liquid,�N.O.S. NA - - <br />1993 III Oil contaminated with halo ens)` <br />CUST MERe7-- <br />Gal. <br />Oil & Water, Non-RCRA Hazardous Waste Liquid <br />CA221 <br />CAD000097432 <br />Gal.' <br />CITY <br />STATE <br />ZIP CO. <br />CITY <br />STATE ZIP CO. <br />PO # <br />745 A West Betteravia <br />Each <br />Drained "Used -Oil Filters <br />_ <br />_ _: __ <br />Drilm <br />PHONE -NO-- <br />CA223 <br />PHONE -NO. <br />Empty Drums <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />( <br />_: 7 - <br />( ) <br />I <br />I <br />I c4bow1-79%10 <br />PRODUCT <br />WASTE <br />CODE <br />MANIFEST QUANTITY <br />NUMBER <br />UNITS PRICE AMOUNT <br />Used oil, Non-RCRA Hazardous Lubricating <br />CA221 <br />Z <br />Gal. <br />Waste, Liquid Industrial <br />CA221 <br />Road 30B <br />Gal. <br />Used. Automotive Anufieeie;Non-RCRA: Hzudous..- <br />Waste Liquid , <br />CA134 <br />Gal. - <br />RQ Waste Combusnble Liquid,�N.O.S. NA - - <br />1993 III Oil contaminated with halo ens)` <br />CA221 <br />FOOUF002 <br />Gal. <br />Oil & Water, Non-RCRA Hazardous Waste Liquid <br />CA221 <br />CAD000097432 <br />Gal.' <br />Waste Solids and Sludges' <br />Env. Svc. ❑ <br />CFR; <br />Gal. <br />Wash Out <br />16604 S. Sr P o <br />745 A West Betteravia <br />Each <br />Drained "Used -Oil Filters <br />_ <br />_ _: __ <br />Drilm <br />Non-RCRA Hazardous Waste Solids (oily debris) <br />CA223 <br />Drum , <br />Empty Drums <br />Drum <br />Transportatio <br />Hrs. <br />Non Hazar us Water <br />Gal. <br />TEST: Clor D Tech 4000,4>ti­ppm Clor D Tech 1000. <br />Pass ❑ Fail ❑ Halogen Detector./Flame Test ass ❑ Fail, <br />Field Service Work Description' <br />Total Charges <br />Other: <br />Other: <br />Vacuum Services Time <br />Out of An- On Site., Off Site <br />Off Load Start Off Load End <br />4��D <br />Return to'Y c <br />TS <br />U Consolidated Manifest <br />Evergreen Oil, Inc. <br />❑ Evergreen Env. Svc. ❑ <br />Evergredn Env. Svc. <br />❑ A1S Filter <br />❑ <br />6880 Smith Ave. <br />Road 30B <br />4139 N. Valentine <br />15131 Clark Ave. <br />Newark, CA -94560 <br />Davis, CA 95926 <br />Fresno, CA 93711 , <br />Industry, CA 91745 <br />CAD980887418 <br />CAD982446874 <br />CAD982446882 <br />CAD000097432 <br />Evergreen Env. Svc.ElEvergreen <br />Env. Svc. ❑ <br />CFR; <br />❑ CFR <br />❑ Greenleaf Env. Svc. <br />16604 S. Sr P o <br />745 A West Betteravia <br />944 E. Slauson Ave. <br />33210 Western <br />.3474 Toyon Circle <br />Carson, CA 9 <br />Santa Maria, CA 93454 <br />Los Angeles, CA 90011 Union City, CA 94587 <br />Valley Springs, CA 95352 <br />CAD98169 0 CAD982446858 - . CAL000110021 CALOOW91507 CAL000214411 <br />Generator certifies that it has established a program to reduce the volume or <br />Source: Ef Collection Station El Government quantity & toxicity of the hazardous waste to the degree determined by <br />❑ Marine L] Agricultural Ll Industrial generator to he economically practicable. <br />I hereby certify `that I `have read and have the authority to <br />bind the above listed generator to the terms on the -reverse <br />n sample # side of this form. e <br />y <br />Dri r Signature Print Name Route # Date en tor's Si ature Print Name Date <br />