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X #��- a rsPos�yy��,,��_�� WORK ORDE ERVICE AGREEMENT <br /> ,4, Evergreen Envi'r�n nta1 Services o <br /> g N_ 380238 <br /> dedicated to the protection of the environment <br /> VF To schedule a pickup, call Send payment to: Sales Oro �7 <br /> 800-596-9455 Evergreen Oil, Inc. <br /> 6880 Smith Ave.,Newark,CA EPA#CAD982413262 P.O. BOX 30517 Z —2,0, <br /> 16540 S. San Pedro St.,Carson,CA EPA#CAD982413262 Los Angeles, CA 90030-0517 Date, !� <br /> GENERATOR/JOB LOCATION BILLING JNMkMATION <br /> NAME CASH❑ CHECK❑ <br /> d/ a07 # <br /> Ann / /IF� �� ADORES n% CuE D�N <br /> CITY SATE Co. c17s fro# <br /> PHONE NO. PROFILE NO. LciUSTO R EP O. <br /> ( ( ) <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> Used oil,Non-RCRA Hazardous Lubricating CA221 Gal. <br /> Waste,Liquid Industrial CA221 Gal. <br /> Used Automotive Anrifr m Non-RCRA Hazardous CA 134 Gal. <br /> Waste Liquid <br /> RQ Waste Combustible Liquid.N.O.S-NA CA221 Gal, <br /> 993 HI(Oil contaminated with halo ens) Ft10)1F002 <br /> Volidsa Waste Lio11quid CA221 Gal. <br /> Was <br /> Wash Out Each <br /> Drained Used Oil Filters Drum <br /> Non-RCRA Hazardous Waste Solids(oily debris) CA223 J. 30 Drum Q© <br /> Empty Drums Drum <br /> Transportation Hrs. <br /> Non Hazardous Water Gal. <br /> Glycol Bulk 50150 Gal, <br /> Glycol Bulk Conc. Gal. <br /> TEST:❑ Clor D Tech 4000 ppm ❑Clot D Tech 1000❑Pass❑Fail ❑ Halogen DetectorMame Test ❑Pass ❑ Fail Q <br /> Field Service Work Description: Total Char es <br /> Other: <br /> Other: <br /> Vacuum Services Time <br /> Out of Yard On Site Off Site Off Load Start Off Load End Return to Yard <br /> TSDF ❑ Consolidated Manifest��1 <br /> ❑ Evergreen Oil,Inc. ❑ Evergreen Env. Svc. ❑ Evergreen Env.Svc. ❑ AIS Filter �I�J <br /> 6880 Smith Ave. Road 30B 4139 N.Valentine 15131 Clark Ave. <br /> Newark,CA 94560 Davis,CA 95616 Fresno,CA 93722 Industry,CA 91745 <br /> CAD980887418 CAD982446974 CAD992446882 CAD000097432 <br /> ❑ Evergreen Env.Svc. ❑ Evergreen Env. Svc. CFR CFR PoRS,, �.j <br /> 16604 S.San Pedro 745 A West Betteravia 944 E. Slauson Ave 33210 Western A34 7 <br /> Carson,CA 90746 Santa Maria,CA 93454 Los Angeles,C Union City,CA 94587 Valley Springs,CA 95352 <br /> CAD981696420 CAD982446859 CAL0001100 CAL000091507 CAL000214411 <br /> Generator certifies that it has established a program to reduce the volume or <br /> Source: ❑Collection Station ❑Government quantity&toxicity of the hazardous waste to the degree determined by <br /> ❑Marine ❑ Agricultural ❑ Industrial generator to be economically practicable. <br /> I hereby certify that I have read and have the authority to <br /> bind 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 25250.9, Evergreen hereby advises customer that customer's shipment of used oil may be <br /> transported to a facility that is required to comply with federal regulations applicable to management of used oii, but that is not required to <br /> comply with the more stringent requirements applicable to hazardous waste management facilities. California facilities that handle or process used <br /> oil are required to meet those more stringent requirements, and some out-of-state facilities that process used oil also meet those requirements. <br /> These include more stringent leak detection and prevention requirements, engineering certifications of tank integrity, and financial assurances for <br /> 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 <br /> and not these more stringent requirements. This notification is for information purposes only. <br /> C <br /> Driver Siunature Print Name Route # Date Generator's Signature Print Name Date <br />