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WORK ORDP—/SERVICE AGREEMENT <br /> Evergreen Envimianental Services NO 580428 <br /> dedicated to the protection of the environment 1 <br /> / To schedule a pickup,,call Send payment to: Sales Order ,�/ 7Z7T <br /> 800-596-9455 Evergreen Oil,Inc. <br /> 6880 Smith Ave..Newark,CA EPA#CAD982413162 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 /> NAME - CASH CHECK <br /> DJC MQIESS A DR OMER CODE NO. <br /> C7AAsyy <br /> CITY STATE ZIP CO. CITY RATE ZIP CO. PO# <br /> ONE NO. tZ- PHO[E NO. PROFILE NO. CUSTOMER EPA ID NO.cl <br /> '�1 <br /> PRODUCT .WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> Used oil,Non-RCRA Hazardous Lubricating CA22Z Gal. <br /> Waste,Liquid Industrial CA221 ` Gal. <br /> Usd Automotive Antifreeze Num RCRA Hoeurdone CAI Gal. <br /> Waste Li aid <br /> RQ Wrote Comlu,illel-,Uil.ND.S.NA CA221 Gal <br /> 1"311t(Oil contaminated wnM1 M1alu enzl F001ffW2 <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 5 50/Specify Product Gal. <br /> Glycol Btt Cone./Specify Product Gal. <br /> TEST:MClor D Tech 4 ppm ❑Clor D Tech 1000 Pass ❑Fail <br /> Retain sample# Total Charges <br /> Required C.1 ti <br /> Field Service Work Description: <br /> Other: <br /> Other: <br /> TS Consolidated Manifest D VER CHECKLIST <br /> Evergreen Oil.Inc. Evergreen Oil.Inc.-Davis Evergreen Oil,Inc.-Fresno [I Time In Time <br /> 6880 Smith Ave: ❑ Road 30B ❑ 4139 N.Valentine <br /> Newark,CA 94560 Davis,CA 95616 Fresno,CA 93722 ❑ Tank/Drllitl Properly Labeled <br /> CAD980887418 CAD982446874 CAD982446882 ❑ Accumulation Start Wtc M;ukcd <br /> ❑ Evergreen Env.Svc. ❑ Ev tma0il,lrc.-SatlatMaia❑ ❑ House Keeping-Tank/Drum[Toon <br /> 16604 S.San Pedr 745 A West Betteravia ❑ Other.Ser%ices Checked: ❑ Oil. ❑ Fillers/Drums. ❑Anlifrteze <br /> Carson,1 9I Santa Maria. 5S 93454 ❑ Culled in other services needed Oil. ❑ FihecdDrums, Antifreeze <br /> CADYSf 6964 CAD9a2ria.0 ❑ ❑ <br /> Generator certifies that it has established a program to reduce the volume or <br /> Source: 2rCollection Station ❑Government quantity&toxicity of the hazardous waste to the degree determined by <br /> ❑ Marine El Agricultural Ll Industrial generator to be economically practicable. <br /> I hereby certit'y that I have read and have the authority to <br /> hind 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 /> oila e required to meet those more stringent requirements,and some out-of-state facilities that process used oil also meet those requirements. <br /> Th include more stringent leak detection and prevention requirements,engineering certifications of tank integrity,and financial assurances for <br /> cl "and accidental releases.his lawful to send used oil to out-of-state facilities that comply only with federal used oil management standards <br /> a of these more stringentn'wrements.This notification is for information purposes <br /> I ver Signature Print Name Route# Date Ge ra is ie t e Print Name Date <br />