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J, WORK ORDER/SERVICE AGREEMENT
<br />--�'/ Evergreen Environmental Services N° 398120
<br />dedicated to the protection of the environment
<br />To schedule a pickup, call Send payment to: Sales Order #
<br />800-596-9455 Evergreen Oil, ltic.
<br />6880 Smith Ave., Newark, CA EPA# CA0982413262 P.O. BOX 30517 a - ��
<br />16540 S. San Pedro St., Carson. CA EPA# CAD9e2413262 Los Angeles, CA 90030-0517 Date:
<br />GENERATOR/JOB LOCATION BILLING INFORMATION
<br />PRODUCT
<br />NAME
<br />CASH [] CHECK Lj
<br />Used oil, Nun-RCPA Hazardous Lubricating
<br />CA221
<br />Oral.
<br />ADDRESS
<br />ADDRESS
<br />CUSTOmF-R CODE NO.
<br />11 "' � = ivq Anarneu, Nos-IiCftA Hara,sFn�n
<br />CA134
<br />Gal,
<br />CI STATE ZIP CO.
<br />CITY STAT; ZIP CO.
<br />P) #
<br />O.
<br />PHQNF, NO.
<br />PROFILE NO.
<br />CUSTOMER EPA ID NO.
<br />GaL
<br />Wash Out
<br />PRODUCT
<br />WASTE
<br />CODE
<br />MANIFEST QUANTITY UNrTS PRICE ANIOUNT
<br />NUMBER
<br />Used oil, Nun-RCPA Hazardous Lubricating
<br />CA221
<br />Oral.
<br />Waste, Liquid Industrial
<br />CA221
<br />Gal.
<br />11 "' � = ivq Anarneu, Nos-IiCftA Hara,sFn�n
<br />CA134
<br />Gal,
<br />RQ W..t. Camb-dbu u1oi4 N,0 3. NA
<br />1901 rrl nal p Haled mth lWa enc
<br />C' yet
<br />Il /tN,MJZ
<br />f J�
<br />Oil et water, Non-RCRA Hazardous Waste Liquid
<br />CA--,,
<br />Gal.
<br />Waste Solids and Sludges
<br />GaL
<br />Wash Out
<br />Each
<br />Drained Used Oil )✓niters
<br />Drum
<br />:Jon-RCRA Hazardous Waste Solids (oily debris)
<br />CA223
<br />Drum
<br />Empty Chums
<br />Drum
<br />Transportation
<br />Hr's,
<br />Non Hazardouster
<br />Gal.
<br />Glycol Bulk 50/50
<br />Oral,
<br />Glycol B Coes.
<br />G�,
<br />TEST: Clnr D Tech 40 Z!5@ ppm Clor D Tech 1000Pats
<br />Fail ❑ Halogen Detecmr/Flame Test ❑ P— Fail
<br />Field Service Work Dcseription:
<br />Total Charges
<br />Other:
<br />Othcr:
<br />vacuum S ices Tune
<br />Out of On Site —Off Site
<br />Off Load Strut gift Load End Return to Yard
<br />TS�t�` E� Consolidated Manifest
<br />Evergreen Oil, Inc. Evergreen Env. Svc. n Evergreen Env. Svc. AJS Filter I�
<br />n880 Stuilh Ave, Raid 30B u 4139 N. V ilcntine ❑ I5131 Clark Ave. l J
<br />Newark, CA 94560 Davis, CA 956.16 Fresno, CA 93722 Industry, CA 91745
<br />CAD980887418 CAD982446874 CAD982446882 CADt OW)7432
<br />Evrrgrcen Env, c. Fvcrgteen Env. Svc. ❑ CFR ❑ ChR ❑ Greenleaf Env, Svc,
<br />16riO4 S. San is m 745 A West Betteravia 944 E. Slaust n Avc. 33210 Wcgcm 3474 Toyon Circic
<br />Cason, CA 9r46 Sa,)W Maria, CA 93454 Loa Anggeles, CA 91x]11 Union City,CA 94581 Valleyy S ringgs, GA 95352
<br />CAD981(i9 11 CAD982446858 CAL(M)tilltlQ21 CAL00009507 CALO(1t1�14A11
<br />Generator certifies that it has established a pmgrattl to redutc the volume or
<br />Si)urce: Collection Station ❑ Government quantity & toxicity of the lhaz,`trdnus waste to the degree determined by
<br />❑ Marine ❑ A r ultural ❑ Industrial generator (4) be economically practicable.
<br />1 herebx certify that I have read and have the authority to
<br />hind the above listed ;generator to the terms on the reverse
<br />Retain Sample # side of this form.
<br />IMPORTANT NOTICE REGARDING THE DISPOSITION OF YOUR OIL.
<br />Per California Health and Safety Code Section 25250.4, Evergreen hereby advises Customer that customer's shihtntm 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 rtquircments applicable to hazardous waste management facilities. California facilities that handle or process used
<br />oil arc required n) meet those more stringent requirements, and some out-of-state facilities that proces.a used oil also meet those requirements.
<br />These include more stringent leak detection and prrvenuon requirement~, engineering certitications of tank integrity, and financial assurances for
<br />c urc and accidental relcasrs. It is lawful to send used oil to out-of-state facilities that comply only with federal used oil management standards
<br />t trot these more stringent requirements. This notification is for information purposes only.
<br />Z=i w 14. it. Z7 ,c W
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