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WORK ORDEWSERVICE [AGREEMENT "Y Evergreen EDWamenjal Services dedicated to Ili tectron of the environment' - 0" 2 To schedule a pickup, call Send pa,at enE to: Sales order # 800-596-9455 Evergreen Oil, Inc. 6880 Smith Ave., Newark, CA EPA# CAD982413262 - P.O. BOX 30517 16540 S. San Pedro St., Carson, CA EPA# CAD982413262 Los Angeles; CA -90030-0517 Date: GENERATOR/JOB LOCATION BILLING iNFnRttfemrnnt rvnmrs NAME --_— CHECK❑ADDRESS MER CODE NO. CSTATE ZIP CO. CITY STATE ZIP CO. LEI "'PHONE NO. PHONE NO. PROFH,E NO.MER EPA ID NO. PRODUCT WASTE MANIFEST CODE NUMBER QUANTITY UNITS -PRICE AMOUNT^i Used oil, Non-RCRA Hazardous Lubdcatin9 'CA221 . Gal: Waste, Liquid Industrial CA221 " Us Automotive Antifr¢r ; Nm -RCM Hazardous Ween U .e CA134 Gat. RQ W. ContMtctibk Lpuid. N.OS. NA tws ou mwaminum .,w, taot�momr __ Gal... Oil & Water, Non-RCRA Hazardous Waste Liquid CA221 Gal Waste Solids and Sludges Gal..: Wash Our Each - Drained Used Oil Filters. Drum Non-RCRA Hazardous Waste Solids (oily debris) - 6273 Drum Empty Drums u Drum Transportation Firs Non Hazardous Water Gal. Glycol Bulk 50/50 Gal Glycol Butk .Cont. .Gal. TEST:❑ Clor D Tech 4000_ppm ❑ Our D Tech 1000❑ Pass. ❑ Fail ❑ Halogen DetectodF7ame Test ❑ Pass ❑ Fail - Field Service Work Description: Other. Other. %meq Vacuum Services Time Out of Yard - On Site Off: Site ._off Load Start Off Load Fad Retum to Yard IDI Lf Consolidated Manueot Evergmeo'Oil, Inc.1:1Evergreen Env. Svc. ❑ Evergreen Env. Svc. ❑ AJS Filler F]6880 Smith Ave. RO 306 4139N. Valentine. 15131 Clark Ave. Newark, CA 9456 Davis, CA 95616. Fresno, CA 93722 Industry, CA 91745 CAD980887418 CAD982446874 CAD982446882 CAD000097432 Evergreen Env. Svc. ❑Evergreen Env. Svc. ❑ CFR 1:1CFR ❑ Greenleaf Env. Svc. 16604 S. San Pedro 745 A West Betteravia 944 E Slauson Ave. 33210 Western 3474 Toym Circle Carson, CA 90746 Santa Maria, CA 93454 Los Angeles, CA 90011 Union City, CA 94587 Valley Spprinngs, CA 95352 CAD981696420. CAD982446858 CALOOOII0021 CAL000091507 CAL000214411 Source: ❑Collection Station ❑ Government Generator certifies that it has established a program to reduce the volume or quantity & toxicity of the hazardous waste to the degree determined by Ll Marine ❑ Agricultural ❑ Industrial generator in be economically practicable. I hereby certify that I have read and have the authority to bind the above listed generator to the terms on the reverse Retain sample # side of this form. IMPORTANT NOTICE REGARDING THE DISPOSITION OF YOUR OIL. Per California Health and Safety Code Section 252509, Evergreen hereby advises customer that customer's shipment of used oil may be transported to a facility that is required to comply with federal regulations applicable to management of used oil, but that is not required to comply with the more stringent requirements applicable to hazardous waste management. facilities. California facilities that handle or process used oil are required to meet those more stringent requirements, and some: out-of-state facilities thatprocess used oil also meet those requirements. These include more stringent leak detection and prevention requirements; engineering certifications of tank integrity, and financial assurances for 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 and not these more stringent requirements. This notification is for information purposes only... Driver Sianature Print Name Route # Date Generator's Sienntnre Print Name Tata