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j WORK ORDER/SERVICE AGREEMENT <br /> �� Evergreen Envi mental Services o <br /> dedicated to the protectionof the environment N_ 414375 <br /> To schedule a pickup, call Send payment to: <br /> Sales Order # <br /> 800-596-9455 Evergreen Oil, Inc. <br /> 6880 Smith Ave., Newark,CA EPA#CAD982413262 P.G. BOX 30517 _ <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 Los Angeles, CA 90030-0517 Date: �^ <br /> GENERATORIJOB LOCATION BILLING INFORMATION <br /> NA Z NAME CASH❑CHECK❑ <br /> ADDRESS ADDRESS CU TOMCODE NO. <br /> a <br /> CI Y S ATE ZI CO. CITY STATE ZIP CO. PO# <br /> *.� <br /> PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. <br /> ?1) ( ) <br /> PRODUCT WASTE MANIFEST <br /> CODE NUMBER QUANTITY UNITS PRICE AMOUNT <br /> Used oil,Non-RCRA Hazardous Lubricating CA22 AZwt Aar 180 Gal. <br /> Waste,Liquid Industrial CA221 Gal. <br /> wam Li uid five Anufozm,Nm-RCRA HaaaNmu CA134 Gal. <br /> RQ waste Combusnbk Liquid,N 0.5.NA CAni <br /> 19931n Oil canlammalW wiN halo PonVFW2 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 Hrs. <br /> Non Hazardous)Vater Gal. _ <br /> Glycol Bulk 50150 Gal. <br /> Glycol But KCone. Gal. <br /> TEST: Clor D Tech 400(I�ppm ❑Clor D Tech 1000 Pass❑Fail ❑ Halogen Detector/Flame Test Pass ❑ Fail 't�y, a <br /> Field Service Work Description: Total Charges <br /> Other: <br /> Other: <br /> VacuumAervices Time Q <br /> Out o and On Site Off Site_Off Load Start Off Load End Ret to Yard V 7 <br /> T F Consolidated Manifest <br /> Evergreen Oil,Inc. ❑ Evergreen Env.Svc. ❑ Evergreen Env.Svc. ❑ AJS Filter El <br /> 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 CAD982446874 CAD982446882 CAD000097432 <br /> Evergreen Env.Svc. Evergreen Env.Svc. ❑ CFR 1:1CFR Greenleaf Env.Svc. <br /> 16604 S.San Pedp 745 A West Betteravia 944 E.Slauson Ave. 33210 Western 3474 Toyon Circle <br /> Carson,CA 907p6 Santa Maria,CA 93454 Los Angeles,CA 90011 Union City,CA 94587 Valley Springs,CA 95352 <br /> CAD9816964 CAD982446858 CAL000I10021 CAL000091507 CAL000214411 <br /> Source: gCollection Station ❑Government Generator certifies that it has established a program to reduce the volume or <br /> 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 /> C 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 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 /> 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 /> not these more stringent r irements. Thus notification is for information purposes only. <br /> river Signature Print Name I2tlnte # !lataatnr'c .Cionafirr Pnnl Hama Tlara <br />