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1 <br /> WORK GRDF"/SERVICE AGREEMENT <br /> Evei—green Envir. .mental Services N� 579891 <br /> dedicated to the pimectiou of the environment <br /> To schedule a pickup, call Send payment to: Sales Order# <br /> 800-596-9455 Evergreen Oil,Inc. <br /> 6880 Smith Ave.,Newark,CA EPA#CAD982413262 Dept. LA 23234 <br /> 16.540 S.San Pedro St..Carson,CA EPA#CAD982413262 Pasadena,CA 91185-3234 Date:_ ®t's _'_ <br /> GENERATOR/JOB LOCATION BILLING INFORMATION <br /> NArVE NAME CASH❑ CHECK <br /> ytL3L� # <br /> ADDRESS ADDRESS C ERODE NO. <br /> CIT STATE ZIP CO. CITY STATE ZIP CO. PO# <br /> . . <br /> PHQNE 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 CA2 ALL,- +. Z3" Gal. <br /> Waste,Liquid Industrial CA221 Gal. <br /> Used Auto,O'Ne Antil}eeze.Non-RCRA Haxwdous <br /> ste L �^ Gal. <br /> Wui uid CA 13 v, <br /> RQ Waste Combustible Liquid,N.O.S.NA CA221 Gal. <br /> 1993 In(Oil wntuminuted with halogens) F(ml/F(l(1'_ <br /> Oil&Water,Non-RCRA Hazardous Waste Liquid CA223 Gal. <br /> Non Hazardous Water Gal. <br /> Waste Solids and Sludges Gal. <br /> Wash Out Each <br /> Pressure Washer/Steam Cleaner Day <br /> Transportation Hrs. <br /> Fuel Surcharge % <br /> Glycol Bulk 50// /Specify Product Gal. <br /> Glycol Bulk onc./Specify Product Gal. <br /> TEST:Yclor D Tech 4000Se.>_-�-ppm Clor D Tech 1000 Pass ❑Fail <br /> Retain sample# W Total Charges <br /> Required <br /> Field Service Work Description: <br /> Other: <br /> Other: <br /> r6880 <br /> Consolidated Manifest DRIVER ECKLIST <br /> rgreen Oil,Inc. Evergreen Oil,Inc.-Davis Evergreen Oil,Inc.-Fresno ❑ Time in Time Out <br /> Smith Ave. ❑ Road 30B ❑ 4139'N.Valentine <br /> Newark,CA 94560 Davis,CA 95616 Fresno,CA 93722 ❑ Tank/Drum Properly Labeled <br /> CAD980887418 CAD982446874 CAD982446882 ❑ Accumulation Start Date Marked <br /> ❑ Evergreen Env. c. ❑ EupeenOil.Im-Santa fvWa❑ ❑ House Keeping-Tank/Drum Clean <br /> 16604 S.San dro 74.5 A West Betteravia ❑ Other Services Checked: ❑Oil. ❑ Filters/Drums, ❑,�ntilreeze <br /> Carson.CA 9 746 Santa Maria,CA 93454 <br /> CAD98169 20 CAD982446858 ❑ Called in other services needed ❑Oil, ❑ Filters/Drums,❑Antifreeze <br /> Source: CA Collection 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 ❑ lndustnal venerator 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 /> The include more stringent leak detection and prevention requirements,engineering certifications of tank integrity,and financial assurances for <br /> clo: and accidental releases.It is lawful to send used oil to out-of-state facilities that co. ly only with federal used oil management standards <br /> ant nt t these more stringent requirements.This notification is for infonnationpurpose"6'1 <br /> Ile <br /> -! --1 <br /> D ver Signature Print Name Route# Date Gene Signature Print Name Date <br />