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R A0A T7 0, 4 wrggreen n. -xgumental Services dedicated to the pro n of the environment No To schedule a pickup, call Send payment to: Sales Order # 804-596-9455 Evergreen Oil, Inc. 6880 Smith Ave.. Newark, CA EPA# CAD982413262 Dept. LA 23234 1640 S. San Pedro St., Carson, CA EPA# CAD982413262 Pasadena, CA 91185-3234 Date: "f r— I GENERATOR/JOB LOCATION BILLING INFORMATION NAME NAME CASH ❑ CHECK ❑ > CA2 71103 -VA # A DDRES € ADDRESS CUSTOMER CODE NO. Gal. F CITY STATE ZIP CO. CITY STATE ZIP CO. PO # RQ Waste Combustible Liquid. N.O.S. NA 1993 fit (Oil contaminated with halo ens) CA221 F001/F002 Gal. PHONE NO. PHONE NO.PROFILE NO. CU TOMER EPA ID NO. Non Hazardous Water Gal. PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE CODE NUMBER AMOUNT Used oil, Non-RCRA Hazardous Lubricating CA2 71103 -VA Gal. Waste, Liquid Industrial CA221® Gal. Used Automotive Antifreeze, Non-RCRA Hazardous Waste Li uid CA134 Gal. RQ Waste Combustible Liquid. N.O.S. NA 1993 fit (Oil contaminated with halo ens) CA221 F001/F002 Gal. Oil & Water, Non-RCRA Hazardous Waste Liquid CA223 Gal. Non Hazardous Water Gal. Waste Solids and Sludges Gal. Wash Out Each Pressure Washer/Steam Cleaner Day Transportation Hrs. Fuel Surcharge % Glycol Bulk 50/ �/Specify Product Gal. Glycol Bull one./Specify Product Gal. TEST: 12rclor D Tech 40004"e',ppm ❑ Clor D Tech 1000 Pass ❑ Fail Retain sample # -4, Required Total Charges Field Service Work Description: Other: F . Other: TSDZ Consolidated Manifest Evergreen Oil, Inc. F7Evergreen Oil, Inc. - Davis ❑ Evergreen Oil, Inc. - Fresno 6880 Smith Ave. Road 30B 4139 N. Valentine Newark, CA 94560 Davis, CA 95616 Fresno, CA 93722 CAD980887418 CAD982446874 CAD982446882 ❑ Evergreen Env. Svc.EmgreenOjInc. -Santa Mafia ❑ 16604 S. San Pedr LLL��JJJ 745 A West Betteravia Carson, CA 907,46 Santa Maria, CA 93454 CAD98169690 CAD982446858 crit DRIVER CH C� ❑ Time In Time Out ❑ Tank/Drum Properly Labeled ❑ Accumulation Start Date Marked ❑ House Keeping - Tank/Drum Clean ❑ Other Services Checked: ❑ Oil, ❑ Filters/Drums, ❑ Antifreeze ❑ Called in other services needed ❑ Oil, ❑ Filters/Drums, ❑ 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 herebycertify ertify 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,6quired to meet those more stringent requirements, and some out-of-state facilities that process used oil also meet those requirements. Theseinclude 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 not these more stringent requirements. This notification is for information purposes only. •.� yam, '_.+--...�w�. y.a+- t: _ /�.•' I r r i -' Fr �, r� �E-1 f - � f i�' - -- Driver Signature Print Name Route # Date Generator's Signature' Ptipt`Name Date