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0 <br />lz� - 4 Ev6 -- reen Envil Mental Services 11 <br />�. <br />dedicared to the pro r1 of the envirmznlelzl <br />N 0 - <br />To schedule a pickup, call Send payment to: Sales Order # <br />800-596-9455 v Evergreen Oil, Inc. <br />6880 Smith Ave., Newark; CA EPA# CAD982413262 Dept. LA 23234 r `may <br />1.6540 S. San Pedro St., Carson, CA EPA# CAD982413262 Pasadena, CA 91185-3234 Date: <br />CFRNF,RATOR/IOR 1,0CATION BILLING INFORMATION <br />NAMENAME <br />�V v� ,I <br />Y <br />- <br />CASH [:]CHECK <br /># <br />ADDRESS <br />L t4IL � �nh +^ <br />ADDRESS <br />CUSTOMER CODE NO. <br />CITY 1 STATE r ZIP CO. <br />CITY STATE ZIP CO. <br />PO # <br />PHONE NO.. _ <br />PHONE NO. <br />PROFILE NO. <br />CUS�TO�ME}R EPA ID N0. <br />PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE <br />CODE NUMBER <br />AMOUNT <br />Used oil, Non-RCRA Hazardous Lubricating CA22 �Z"�, C" Gal. <br />Waste, Liquid Industrial CA221 ,b Gal. <br />Used AYLUMOtive Antifreeze, Non-RCRA Hazardous CA134 Gal. <br />Wuste.Liquid <br />RQ Waste Combusdble Liquid, N.O.S. NA CA221 Gal. <br />1993 III (Oil contaminated with halogens) F001/F002 <br />Oil & Water, Non-RCRA Hazardous Waste Liquid CA223 Gal. <br />NonHazardousWater Coal. <br />Waste Solids and Sludges Gal. <br />Wash -Out Each <br />Pressure Washer/Steam Cleaner Day <br />Transportation Hrs. <br />Fuel Surcharge % <br />Glycol Bulk50/S (specify Product Gal. <br />jT <br />Glycol BulkX--c./Specify Product Gal. 1 <br />TEST: R Clor D.Tech 400o. ppm ❑ Clor D Tech 1000 Erpass ❑ Fail <br />Retain Sample# <br />Requited �- <br />Total Charges <br />Field Service Work Description: <br />Other: <br />Other: l <br />^^ <br />tom' 4...! a <br />TS Consolidated Manifest DRIVER C1WCKLIST <br />Evergreen Oil, Inc. F7 Evergreen Oil, Inc. - Davis ❑ Evergreen Oil, Inc. - Fresno ❑ Time In Time Out <br />6880 Smith Ave. Road 30B 4139 N. Valentine ❑ Tank/Drum Properly Labeled <br />Newark, CA 94560 Davis, CA 95616 Fresno, CA 93722 <br />CAD980887418 CAD982446874 CAD982446882 ❑ Accumulation Start Date Marked <br />Evergreen Env. Svc., ❑ EmT=0il lw.-S=Malia❑❑ House Keeping - Tank/Drum Clean <br />16604 S. San Ped 745 A West Betteravia ❑ Other Services Checked: ❑ Oil, ❑ Filters/Drums, 0 Antifreeze <br />Carson, CA 90 6 Santa Maria, CA 93454 ❑ Called in other services needed ❑ Oil, ❑ Filters/Drums, ❑ Antifreeze <br />CAD98169 0 CAD982446858 <br />Generator certifies that it has established a program to reduce the volume or <br />Source: 2f Collection Station ❑ Government quantity & toxicity of the hazardous waste to the degree determined by <br />❑ Marine ❑ Agricultural ❑ Industrial generator to be 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 />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 facilitiesthathandle 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 certificatitans of tank integrity, and financial assurances for <br />claure and 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 not these more stringent requirements. This notification is for information purposes only. <br />_LJt:,. <br />Driver Signature `'Print Name Route # Date = enn'mf ator's Signatures Pref Name Date ,, . <br />