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, I 441, WASTE CODE WORK O"ER/SERVICE AGREEMENT QUANTITY Evergreen Envir nental Services No 372485 Jdedicated to the protection of the environment �j„Q CUSTOMEIt CODE NO. To schedule a pickup, call Send payment to: Sales Order STATE ZIP CO. 800-596-9455 Evergreen Oil, Inc. CA134 6880 Smith Ave., Newark, CA EPA# CAD982413262 16540 S. San Pedro St., Carson, CA EPA# CAD982413262 P.O. BOX 30517 Los Angeles, CA 90030-0517 Date: GENERATOR/JOB LOCATION BILLING INFORMATION PHONE NO. MEl WASTE CODE NAME QUANTITY CASH ❑ CHECK ❑ AD ESS '11 CA22Z,7 ADDRESS �j„Q CUSTOMEIt CODE NO. CIT STATE ZIP CO. CITY STATE ZIP CO. PO # Used Automotive Antifreeze, Non-RCRA Hazardous Waste Liquid CA134 Gal. PHONE NO. CA221 F001/FW2 PHONE NO. PROFILE NO. I CUSTOMER EPA ID NO. S 3 !—Z7" I ( ) Gal. Waste Solids and Sludges Z PRODUCT WASTE CODE MANIFEST NUMBER QUANTITY UNITS PRICE AMOUNT Used oil, Non-RCRA Hazardous Lubricating CA22Z,7 $t f�, �j„Q Gal.j j Waste, Liquid Industrial CA221 Gal. Used Automotive Antifreeze, Non-RCRA Hazardous Waste Liquid CA134 Gal. RQ Waste Combustible Liquid N.O.S. NA 1993 tH Oil contaminated with halo ens CA221 F001/FW2 Gal Oil & Water, Non-RCRA Hazardous Waste Liquid CA221 Gal. Waste Solids and Sludges Gal. Wash Out Each Drained Used Oil Filters Drum Non-RCRA Hazardous Waste Solids (oily debris) CA223 Drum Empty Drums Drum Transportation Hrs, Non Hazardous ater Gal. Glycol Bulk 50/50 Gal. Glycol B Conc. Gal. TEST: Clor D Tech 40029n�-ppm ❑ Clor D Tech 1000 Pass ❑ Fail ❑ Halogen Detector/Flame Test Pass E] Fail z �^; Field Service Work Description: Total Charges Other: Other: Vacuum Se ces Time Out of Y d On Site Off Site Off Load Start Off Load End Return to and ! r 7EV [Consolidated Manifest rgreenOil, Inc. ❑ Evergreen Env. Svc. ElEvergreen Env. Svc. ❑ AJS Filter880 Smith Ave. Road 30B 4139 N. Valentine 15131 Clark Ave. Newark, CA 94560 Davis, CA 95616 Fresno, CA 93722 Industry, CA 91745 CAD980887418 / CAD982446874 CAD982446882 CAD000097432 ❑ Evergreen Env. Sv . 1:1 Evergreen Env. Svc. ❑ CFR ❑ CFR ❑ Greenleaf Env. Svc. 16604 S. San P 745 A West Betteravia 944 E. Slauson Ave. 33210 Western 3474 Toyon Circle Carson, CA 46 Santa Maria, CA 93454 Los Angeles, CA 90011 Union City, CA 94587 Valley Springs, CA 95352 CAD98169V20 CAD982446858 CAL000110021 CAL000091507 CAL000214411 Generator certifies that it has established a program to reduce the volume or Source: 6 Collection Station ❑ Government quantity & toxicity of the hazardous waste to the degree determined by ❑ Marine ❑ Agricultural ❑ Industrial generator to 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 25250.9, 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 that process 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 arA not these more stringent requirements. This notification is for information purposes only. riles S1Pnahlre,, Print Name. Rnnte. # Tlata tan14. r'c Cianatnra Print llama Tlata