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Dec 18 08 03: 54p F _1RD 12 644-8555 p. 4 <br /> WORK ORDE ERVICE AGREEMENT <br /> Evergreen Environmental Sery cies <br /> dedicated to the protection of the environment N-0 423.9- 40 <br /> / To schedule a pickup, call Send pa;.taint to:' Sales Order# <br /> 800-596-9455 Evergreei 0 1,Inc. <br /> 6680 Smith Ave.,Newark,CA EPA#CAD982413262 P.O.BG m�10517 <br /> 16540 S.San Pedro St.,Carson,CA EPA#CA0982413262 Los Angeles,(A )0030-0517 Date: <br /> GFNERATOR/JOB LOCATION BILLING IN i0RMATION <br /> NAME — <br /> i NAME CASH❑CHECK❑ <br /> ADDRESS — # <br /> ADDRESS CUSTOMER CODE NO. <br /> CITY —STATE. ZIP CO. CITY STATE ZIP CO. PO# <br /> PHONE NO. PRONE NO. PROFILE NO. CUSTOMER EPA ID NO. <br /> t_ ( 1 <br /> PRODUCT WASTE MANEFEST <br /> CODE NUMBER QUANTITY UNITS PRICE AMOUNT <br /> Used oil,Non-RCRA Hazardous Lubricating CA221 Gal <br /> Waste.Liquid Industrial CA221 Gal. <br /> 11—i Automotive Amifr .,Non•RCRA Halm, CA 134 <br /> Waste L ukl Mh <br /> 0 Weue Comlw.yiWe Liquid,N.OS.NA CA221 <br /> 1993 IN(0,1 mmomi 1 with Irnl ,a F001/F(102 <br /> Oil&Water,Non-RCRA Hazardous Waste Liquid CA221 G.J. <br /> Waste Solids and Sludges <br /> Wash Out <br /> Drained Used oil Filters - <br /> Non-RCRA Hazardous Waste Snlids(oily debris) CA223 <br /> Empty Drums <br /> Transportation rs <br /> Non Hazardous WaterGlycol Bulk 50 <br /> /50 <br /> Glycol Bulk Conc. Gal <br /> TEST:❑Clor D Tech 4000_ppm ❑Clor D Tech 1000❑Pass❑Fail ❑ 4a ogen Detector/Flame Test Pass <br /> _ ❑ ❑Fail <br /> Field Service Work Description: _ Total Charges <br /> Other: rr, <br /> Other. — <br /> Vacuum Services Time — <br /> Out or Yard On Site Off Site Off Load Stan 0fl Load End Return to Yard <br /> TSDF ❑ Consc.lidated Manifest <br /> ❑ Evergreen Oil,Inc. ❑ Evergreen Env.Svc. ❑Evergreen Env.Svc. f AJS Filter ❑ <br /> 6880 Smilh Ave_ Road 30B 4139 N.Valentine LJ 15131 Clark Ave. <br /> Newark,CA 94560 Davis,CA 95616 Fresno,CA 93722 industry,CA 91745 <br /> CAD980887418 CA0982446874 CAD982446882 CAD000097432 <br /> ❑ Evergreen Env.Svc. ❑ Evergreen Env.Svc. ❑CFR CFR ❑ Greenleaf Env.Svc. <br /> 16604 S.,San Pedro 745 A West Betteravia 944 E.Slauson Ave. � � 33210 Western 3474 Toyon Circle <br /> Carson,CA 90746 Santa Muria,CA 93454 Los Anocles,CA 9001 i Union City CA 94587 Valley Springs,CA 95352 <br /> CAD981696420 CAD982446858 CAL000110021 CAL000001507 CAL000214411 <br /> Source: ❑Collection-Station ❑GOVernment (lenerator certifies that it has established a program to reduce the volume or <br /> caantity&toxicity of the hazardous waste to the degree determined by <br /> ❑Marine 0 Agricultural 0 Industrial gmemtor to be economically practicable. <br /> I hereby certify that I have read and have the authority to <br /> Retain Sample # kind the above listed generator to the terms on the reverse <br /> s de of this form. <br /> IMPORTANT NOTICE REGARDING T12 DISPOSITION OF YOUR OIL. <br /> Per California Health and Safety Code Section 25250.9, Evergreen hereby ad rises customer that customer's shipment of used oil may be <br /> transported to a facility that is required to comply with federal regulations ar Ili(able to management of used oil,but that is not required to <br /> comply with the more stringent requirements applicable to hazardous waste r anagement facilities.California facilities that handle or process used <br /> oil are required to meet those'IYft11t'stringent requirements, and some out-of :rte facilities that process used oil also meet those <br /> requirements. <br /> These include more stringent`trtfk'detection and prevention requirements,end uecring certifications of tank integrity,and financial assurances for <br /> 'Xi closure and accidental releaser'Ifis awful to send used oil to out-of-state fa(ilit es that comply only with federal used oil management standards <br /> and not these more stringent requirements.This notification is for informadoi ptrposes only. <br /> - r <br /> Driver.SiLmature Print Name Route# nate —Generator's Signaulre Print.Name bate <br />