Laserfiche WebLink
WORK ORDER/SERVICE AGREEMENT <br /> Evergreen Env mental Services * N° 685022 <br /> dedicated to the p nan of the environment �,,,.�-�t� <br /> To schedule a pickup, call Send payment to: Sales Order# qf3 <br /> 800-972-5284 Evergreen Oil,Inc. <br /> �- 6880 Smith Ave.,Newark,CA EPA#CAD982413262 Dept.LA 23234 <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 Pasadena,CA 91185-3234 Date: <br /> GENERATOR/JOB LOCATION BILLING INFORMATION <br /> NAMFA NAME CASH Q CHECK F] <br /> V or�4I # <br /> ADDRESS ADDRESS CUSTOMER CODE NO. <br /> G.3 Z <br /> ACI I I STATE ZIP CO. CITY STATE ZIP CO. PO# <br /> v b <br /> PHCO.NE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> Used oil,Non-RCRA Hazardous Lubricating CA22 Gal. <br /> Waste,Liquid Industrial CA221 Gal. <br /> Uud li' iw Ansif w,Non-RCRAHm s CA13 -��� Gal, <br /> Wassc Luid <br /> RQ W-R Cambuasible Liqui4ish N.O.S.NA CA221 Gal. <br /> 19931n OJ contamiiated whal Pe01rtUo2 <br /> Oil&Water,Non-RCRA Hazardous Waste Liquid CA223 Gal. <br /> Non Hazardous Water Gal. <br /> WasteSolids and Sludges Gal. <br /> Wash Out Each <br /> Pressure Washer/Steam Cleaner Day <br /> Transportation His. <br /> Fuel Surcharge % <br /> Glycol Bulk 50/ Specify Product Gal. <br /> Glycol Bulk ncJSpecify Product Gal. <br /> TEST: Clar D Tech 4000.E 20 ppm ❑Clor D Tech 1000 Pass ❑Fail <br /> Retain sample# Total Charges <br /> Required 1 G l 3 <br /> Field Service Work Description: <br /> Other: <br /> Other: <br /> TSD Consolidated Manifest DRIV HECKLIST <br /> vergreen Oil,Inc. Evergreen Oil,loc. Evergrcen Oil,Inc.-Fresno ❑ Time In Time Out <br /> 6880 Smith Ave. ❑ Read 30B -Davis[:] 4139 N.ValenWe El Tank/Drum Properly Labeled <br /> Newark,CA 94560 Davis,CA 95616 Fresno,CA 93722 <br /> CAD980887418 CAD982446974 CAD982446882 ❑ Accumulation Start Date Marked <br /> Evergreen Env.Svc. Esi*mMirc-SasaMaia❑ ❑ House Keeping-Tank/Drum Clean <br /> 16604 S.San Pedro El 745 A West Betterevia ❑ Other Services Checked: 13 Oil, ❑ Filters/Dmms, ❑Antifreeze <br /> Carson,CA9 Santa Maria,CA 93454 ❑ Called in other services needed Oil, E] FFilters/Drums,C Antifreeze <br /> CAD98169 D6 CAD982446858 <br /> Generator certifies that it has established a program to reduce the volume or <br /> Source: Collection Station ElGovernment 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 /> 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 oil,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 /> clos 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 these more stringent requirements.This notification is for information purposes ony. () <br /> ver Signature Print Name Route# ate Generato 's ignature Print Name Date <br /> White Copy=Customer Copy-Pink&Yellow Copy=Office Use-Green Copy=Attach manifest-Golden Copy=Driver Copy <br />