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t 4WORK ORDE12, �(SERVICE AGREEMENT <br /> ® Evergreen Envirinental Services • N° 372484 <br /> r dedicated to the protection of the environment <br /> To schedule a pickup, call Send payment to: Sales Order # <br /> 800-596-9455 Fvergreen Oil, Inc. <br /> 6880 Smith Ave., Newark,CA EPA#CAD982413262 P.O. BOX 30517 C <br /> 16640 S.San Padre St.,Carson,CA EPA#CAD982413262 Los Angeles, CA 90030-0517 Date: <br /> GENERATOR/JOB LOCATION BILLING INFORMATION <br /> N ME _ NAME CASH❑ CHECK❑ <br /> w+.� # <br /> ADDRESS ADDRESS CUS ,MER CODE NO. <br /> J t- /�.vZ o Z <br /> CITY STATE ZIP CO. CITY STATE ZIP CO. PO# <br /> GQ 96LOh <br /> PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. <br /> PRODUCT UCA221 <br /> MANIFEST QUANTITY UNTTS PRICE AMOUNT <br /> NUMBER <br /> Used oil,Non-RCRA Hazardous Lubricating647$y/,) 'b Gal. ,rte ��'••� <br /> Waste,Liquid Industrial Gal, <br /> Uml Automotive Amificer,Non-RCRAHazardous Gal. <br /> ,:ma and Ro Waue ComhsOle Liquid,N 0.5.NA 1993mn rnmnen n: Gal. <br /> Oil&Water,Non-RCRA Hazardous Waste Liquid CA221 Gal. <br /> Waste Solids and Sludges Gal. <br /> Wash Out Each <br /> Drained Used Oil Filters Drum <br /> Non-RCRA-Hazardous Waste Solids(oily debris) CA223 Drum <br /> Empty Drums Drum <br /> Transportation Hts <br /> Non Hazardous Water, Gal <br /> Glycol Bulk ?5150 Gal. <br /> Glycol Be 1;..Conc. Gal. <br /> TEST: Work <br /> Tech 4000ppm ❑Or,D Tech 1000 Pass ❑Fail ❑ Halogen DetectodFlame Test Pass ❑ Fail , <br /> Field Se Description, 3THes <br /> Other: <br /> Other: <br /> Vacuum Services Time Out of and On Site Off Site Off Load Start Off Load End Retum to ard <br /> TS Consolidated Manifest <br /> 111880 <br /> vergreen Oil,Inc. ❑ Evergreen Env.Svc. Evergreen Env.Svc. ❑ AIS Filter <br /> Smith Ave. Road 30B 4139 N.Valentine 15131 Clark Ave. <br /> Newark,CA 94560 Davis,CA 95616 Fresno,CA 93722 Indus VVyy CA 91745 <br /> CAD980887418 CAD982446874 CAD982446882 CAD000097432 <br /> ❑ Evergreen Env. c. Evergreen Env.Svc. ❑ CFR ❑ CFR Greenleaf Env.Svc. <br /> 16604 S.San P dro 745 A West Betteravia 944 E.Slauson Ave. 33210 Western 3474 Toyon Circle <br /> Carson,CA 9 46 Santa Maria,CA 93454 Los Angeles,CA 90011 Union City,CA 94587 Valley Springs,CA 95352 <br /> CAD98169 CAD982446858 CAL(100110021 CAL00009I507 CAL000214411 <br /> Generator certifies that it has established a program to reduce the volume or <br /> Source: A.` lCction 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 # Z G 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 /> cld re 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 /> a of these more stringent requirements.This notification is for information purposes only. <br /> qT) 'v,=r Sionahrrr print Name TA.,._ <br />