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7-4 77 Evergreen EIS-viaerilval Services 2-1 'tn dedicated 10 the prat t gj'the environment To schedule a pickup, call Send payment to: Sales Order # 800-596-9455 Evergreen Oil, Inc. 6880 Smith Ave., Newark, CA EPA# CAD982413262 Dept. LA 23234 16540 S. San Pedro St.. Carson, CA EPA# CAD982413262 Pasadena, CA 91185-3234 Date: f'VXTVlD A'PnD/1"R I nil ATrnN RUJ ING INFORMATION NAME WASTE MANIFEST QUANTITY CODE NUMBER UNITS PRICE AMOUNT NAME CA221 , r" '!- `= F � „�� CASH ❑ CHECK Waste, Liquid Industrial CA221 -. -7Q ® S - Gal. Used Automotive Antifreeze, Non -ACRE. Hazardous waste Li uid CAI 3 m - _ . ,q W "``"„? _ +4 `+ %�i•�'�^ . --•'s'�'. ;'•••"- Gal. � DDRESS F0000'02 D Gal. ADDRESS CA223 CUSTOMER CODE NO. Non Hazardous Water w Gal. Waste Solids and Sludges Gal. CITY STATE ZIP CO. CITY STATE ZIP CO. PO # .� PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. IA - PRODUCT WASTE MANIFEST QUANTITY CODE NUMBER UNITS PRICE AMOUNT Used oil, Non-RCRA Hazardous Lubricating CA221 , r" '!- `= F � „�� Gal. Waste, Liquid Industrial CA221 -. -7Q ® S - Gal. Used Automotive Antifreeze, Non -ACRE. Hazardous waste Li uid CAI 3 m - _ . ,q W "``"„? _ +4 `+ %�i•�'�^ . --•'s'�'. ;'•••"- Gal. RQ Waste Combustible Liquid, N.O.S. NACAR 1993 In (Oil contaminated with halo ensl F0000'02 D 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 50/50/Specify Product Gal. Glycol Bu11�:Conc./Specify Product' Gal. TEST: ®JClor D Tech 4000= _�;, ppm ❑ Clor D Tech 1000 Pass ❑ Fail Detain sample # . Total Charges Required Field Service Work Description: Other: Other: N TSDI' IJ Consolidated Manifest DRIVER -CHECKLIST Evergreen Oil, Inc. Evergreen Oil, Inc. - DavisEvergreen Oil, Inc. - Fresno ❑ Time In Time Out 6880 Smith Ave. ❑ Road 30B ❑ 4139 N. Valentine ❑ Tank/Drum Properly Labeled Newark, CA 94560 Davis, CA 95616 Fresno, CA 93722 CAD980887418 CAD982446874 CAD982446882 ❑ Accumulation Start Date Marked ❑Evergreen Env. Svc, ❑ EveipmOil,Inc.-SantaMaria❑ ❑ House Keeping - Tank/Drum Clean 16604 S. San Pedro 745 A West Betteravia ❑ Other Services Checked: ❑ Oil, ❑ Filters/Drums, ❑ Antifreeze Carson, CA 90746 Santa Maria, CA 93454 ❑ Called in other services needed ❑ Oil, ❑ Filters/Drums, ❑ Antifreeze CAD981696420 CAD982446858 Generator certifies that it has established a program to reduce the volume or Source: ETCollection Station ❑ Government quantity & toxicity of the hazardous waste to the degree determined by ❑Marine ❑Agricultural ❑Industrial generator to be economically practicable. I hereby certify 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 required to meet those more stringent requirements, and some out-of-state facilities that process used oil also meet those requirements. These include 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. Driver Signature Print Name Route # Date Generator's Signature Print Name Date