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IF, WASTE CODE WORK ORDER/SERVICE AGREEMENT �j Evergreen Envi_ mental Services No- 411576 CA22 dedicated to the protection of the environment To schedule a pickup, call Send payment to: I - 1 Sales Order # w OQ�1Z.--M CUS O R CODE NO. I 800-596-9455 Evergreen Oil, Inc. CITY 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: �t 7 GENERATOR/JOB LOCATION BILLING INFORMATION N44E 1M9hv a WASTE CODE NAME QUANTITY CASH ❑ CHECK ❑ # ADDRESS ZOj- r CA22 ADDRESS CUS O R CODE NO. I CITY STATE c ZIP CO. CITY STATE ZIP CO. PO # FPHONE NO. CA 134 PHONE NO. PROFILE NO. CUSTOMER EPA ID N0. PRODUCT WASTE CODE MANIFEST NUMBER QUANTITY UNITS PRICE AMOUNT Used oil, Non-RCRA Hazardous Lubricating CA22 Gal. Waste, Liquid Industrial CA221 Gal. Used Automotive Antifreeze, Non-RCRA Hazardous Waste Li uid CA 134 Gal. RQ Waste Combustible Liquid, N.O.S. NA 1993 Ill Oil contaminated with halo ens CA221 F001/F002 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 Hazardoustater Gal. Glycol Bulk 50/50 Gal. Glycol Buy_ Cone. Gal. TEST: Clor D Tech 4000j -P& ppm ❑ Cl., D Tech 1000 ZPasiD Fail ❑ Halogen Detector/Flame Test ❑ Pass ❑ Fail Field Service Work Description: Total Charges Other: Other: Vacuum Se Ices Time Out of Y d On Site Off Site Off Load Start Off Load End Return tDNgrd TS Evergreen Oil, Inc. 6880 Smith Ave. Newark, CA 94560 CAD980887418 X Consolidated Manifest ❑Evergreen Env. Svc. ❑ Evergreen Env. Svc. [:]AJS Filter ❑ Road 30B 4139 N. Valentine 15131 Clark Ave. Davis, CA 95616 Fresno, CA 93722 Industry, CA 91745 CAD982446874 CAD982446882 CAD000097432 ❑Evergreen Env. S c. ❑ Evergreen Env. Svc. ❑ CFR ❑ 16604 S. San Pe oc 745 A West Betteravia 944 E. Slauson Ave. Carson, CA 90 6 Santa Maria, CA 93454 Los Angeles, CA 90011 CAD9816964 CAD982446858 CAL000110021 Source: Collection Station ❑ Government ❑ Marine ❑ Agricultural ❑ Industrial Retain sample # 7 c— Z CFR ❑ Greenleaf Env. Svc. 33210 Western 3474 Toyon Circle Union City, CA 94587 Valley Springs, CA 95352 CAL000091507 CAL000214411 Generator certifies that it has established a program to reduce the volume or quantity & toxicity of the hazardous waste to the degree determined by generator to be economically practicable. I hereby certify that I have read and have the authority to bind the above listed venerator to the terms on the reverse 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 losure and accidental releases. It is lawful to send used oil to out-of-state facilities that comply only with federal used oil management standards not these more stringent requirements. This notification is for information purposes only. ►:f% river Siunahtre, Print Name Rnnte 4 DAtP h f ra nr'c .ql natnrt-Print Name IlatP