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f 'EVERGREEN QIL INC. D6A <br />6860 Smith Avenue EVERGREEN ENVIRONMENTAL SERVICES, INC. <br />Newark, CA 945M <br />OffiFax: (5 1) 744 9680 AUTHORIZATION FOR SERVICE <br />Fax:(510)7A4-9$SO <br />4; NEW CUSTOMER ❑ EXISTING CUSTOMER ❑ ADDRESS CHANGE ❑ RATE CHANGE ❑ DNU <br />CUSTOMER CODE <br />SITE LOCATION <br />NAME: 4 gywe5, 6"5 & �oo D PHONE: CD3-8�3r✓?�/,� <br />ADDRESS: lGIy� "% l/go� CONTACT: o&-eeSA jno t:� <br />CITY & STATE ,/ ��=�/ ,orf- ZIP <br />VERIFIED EPA I.D. # G'.*4,920a _jealig;6_ <br />BILLING INFORMATION (REQUIRED) <br />NAME: PHONE: <br />ADDRESS: <br />CITY & STATE <br />FAX & EMAIL <br />USED OIL <br />$ <br />PER <br />OIL FILTERS <br />$ <br />PER <br />USED ANTIFREEZE <br />$ <br />PER <br />GLYCOL <br />$ <br />PER <br />(TYPE) <br />BILLING CONTACT <br />ZIP <br />DRUM DISPOSAL <br />(SIZE & TYPE) <br />NON-RCRA WATER <br />NON-RCRA SOLIDS <br />NON-HAZ WATER <br />$ PER <br />$ PER <br />$ PER <br />$ 2/0�7PER :r i <br />GLYCOL $ PER NON-HAZ SOLIDS $ PER <br />(TYPE) <br />FLAMMABLE LIQUIDS $ PER TRANSPORTATION $ PER <br />(HIGH BTU) - LOW WATER <br />FLAMMABLE LIQUIDS - $ PER OTHER $ PER <br />(LOW BTU) - HIGH WATER <br />DRUM SET-UP $ PER OTHER $ PER <br />(SIZE & TYPE) <br />Notes: <br />Conditions and Terms_ <br />1) Terms of this agreement are from the dates of to <br />2) Prices for services provided by EVERGREEN to the CUSTOMER are considered confidential, and shall not be shared with any EVERGREEN competitor for <br />any reason. <br />3)EVERGREEN will submit statements to Customers for all charges that occur pursuant to this Agreement. The CUSTOMER will pay EVERGREEN within <br />thirty (30) days from the issuance of this statement. A tate payment charge of one and one-half percent (1'/-.%) per month may be charged on any amount not paid <br />within .thirty (30) days of the invoice date, payment thereafter will be applied first to the accrued lads payment charges and then to the principal amount. In the <br />event any changes are past due, EVERGREEN may, at its option upon notice of 10 days, discontinue. services, return materials, and with ]d deliv y of reports <br />or any other date pending receipt of payment for all services rendered. 7 <br />ACCEPTED Z ,0,V,$Az`P J�DO.J OFFERED Ll ��s-✓ <br />CUS M R NAME (PRINTED) SALESIDRIVER NAME ( NTED) <br />CUSTOMER SIGNATURE DATE S SAI SIGNATURE DATE <br />2 -Cl X1 3 13C213Sd-1 dH Wd9 l t Z T O T OZ Ga SEC <br />