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Evergreen irvir > ent-aY.l Services dedicated io the pi ec i of the envinmtnent To schedule a pickup, call 800-596-9455 6880 Smith Ave.. Newark. CA EPA# CAD982413262 16540 S. San Pedro St.. Carson, CA EPA# CAD982413262 ('_FNRI?AT(1R/UIR 1.0('ATTON Send payment to: Evergreen Oil, Inc. Dept. LA 23234 Pasadena, CA 91185-3234 RI A JISIG INFORMATION Sales Order # Date: N �f, NAME CASH CHECK Waste, Liquid Industrial CA221 a ' a Gal. A,DD�RgEi� im a tIO�T 1 w "w tom^. ADDRESS CUS'IOI�t �C CI1W STATE --ZIP CO. CITY STATE ZIP CO. PO # Oil & Water, Non-RCRA Hazardous Waste Liquid CA223 Gal. NE N_O._ PHONE NO. PROFILE NO. CUSTOMER EPA ED NO. Gal. Wash Out PRODUCT WASTE I MANIFEST I I CODE NUMBER QUANTITY I UNITS I PRICE I AMOUNT Used oil, Non-RCRA Hazardous Lubricating CA2t ' �7 („ ) Gal. Waste, Liquid Industrial CA221 a ' a Gal. Used Automotive Antifreeze. Non-RCRA Hazardous Waste Li Hid C`A 1 'r±^ !,�„ - Gal. RQ Waste Combustible Liquid, N.O.S. NA 1993 In (Oil contaminated with halo ens CA221� FOO 1/F002y�� 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 B Conc./Specify Product Gal. M, , TEST: 6 Clor D Tech 404 ppm ❑ Clor D Tech 1000 Pass Fail Retain sample # 114 Total Charges Required - Field Service Work Description: Other: } Other: tt TL16880 U Consolidated Manifest DRIVE CHECKLIST Evergreen Oil, Inc. Evergreen Oil, Inc. - Davis Evergreen oil, Inc. - Fresno ❑ Time In Time Out _ Smith Ave. Road 30B ❑ 4139 N. Valentine Newark, CA 94560 Davis, CA 95616 Fresno, CA 93722 ❑ Tank/Drum Properly Labeled CAD980887418 CAD982446874 CAD982446882 ❑ Accumulation Start Date Marked ❑Evergreen Env. Svc. ❑ Ev�V=0il.lnc.-SantaMana❑ ❑ House Keeping - Tank/Drum Clean 16604 S. San Pedes 745 A West Betteravia ❑ Other Services Checked: ❑ Oil, ❑ Filters/Drums, ❑ Antifreeze Carson, CA 907 6 Santa Maria, CA 93454 CAD981696 CAD982446858 ❑Called in other services needed ❑Oil, ❑ Filters/Drums, p Antifreeze Generator certifies that it has established a program to reduce the volume or Source: Collection Station ❑ Govemment 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 Forint Name Route'# Date Generator's Signature Print Name Date