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+°�� vel"reels Envirgib,nental Services271' 93 Y sw dedicated to the /nit m gJthe enrirolamerar 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 y 16540 S. San Pedro St., Carson, CA EPA# CAD982413262 Pasadena, CA 91185-3234 Date: GENERATOR/JOB LOCATION BILLING INFORMATION PRODUCT NAME MANIFEST NUMBER CASH [] CHECK AMOUNT Used oil, Non-RCRA Hazardous . Lubricating CA2 ;70 LDDRESSH" Z g2- ADDRESS Waste, Liquid Industrial CjJSTOME ODF VO. € C Y STATE ZIP CO. CITY STATE ZIP CO. PO # CA 134 Gal. HONE NO. PHONE NO.PROFILE NO. CUSTOMER EPA ID NO. Oil & Water, Non-RCRA Hazardous Waste Liquid CA223 Gal. PRODUCT WASTE CODE MANIFEST NUMBER QUANTITY UNITS PRICE AMOUNT Used oil, Non-RCRA Hazardous . Lubricating CA2 ;70 '` 7/00 Gal. Waste, Liquid Industrial CA22 - Q® Gal. Used Automotive Antifreeze, Non-RCRA Hazardous Waste Li uid CA 134 Gal. RQ Waste Combustible Liquid, N.O.S. NA 1993 111 (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. G1yco1;Bu1 onc./Specify Product Gal. TEST: Cl., D Tech 4001Y ---' ppm ❑ Clor D Tech 1000 e Pass ❑ Fail Retain Sample # Required Total Charges Field Service Work Description: Other: Other:, e TSDF 1/'l Consolidated Manifest Evergreen Oil, Inc. ❑ Evergreen 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. SvP` EmgeerlOi1,lnc-SanraMxiao 16604 S. San Pedddfffo 745 A West Betteravia. Carson. CA 90/46 Santa Maria, CA 93454 CAD98169610 CAD982446858 Source: YJ Collection Station ❑ Government ❑ Marine ❑ Agricultural ❑ Industrial ±nmi DRIVER CIMCKLIST ❑ Time to 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 quantity & toxicity of the hazardous waste to the degree determined by generator to be economically practicable. I herebycertify ertify that I have read and have the authority to bind the above listed venerator 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/arse 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. 0.. ,Driver Signature Print Name Route # Date GenerWr's Signature: Print Name Date; , ;;