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Jlz WORK ®RDER/SERVICE AGREEMENT <br /> Evergreen Environmental Services N® 6,93259 <br /> dedicated to the protection of the environment <br /> To schedule a pickup,call Send payment to: Sales Order#L-k <br /> 800-9725284 Evergreen Oil,Inc. <br /> 6880 Snaith Avc.,Newark,CA EPA#CAD982413262 rept.LA 23234 e �' <br /> 16540 S.San Pcdro St.,Carson,CA &PA#CAD9S2413262 Pasadena,CA 91185-3234 Date: <br /> GIJNE,RATOR/JOB LOCATION BILLING INFORMATION <br /> fE NAIVE CASH[]CHECIf E t <br /> l t? C a t�V YI•+t �}w.� # <br /> ADDRESS ADDRESS CUSTOMER CODE NO, <br /> ®�j <br /> CITY STATE ZIP CO. CITY STATE ZIP CO. PO It . <br /> PRONE NO, PHONE NO. PROFILE NO. CUSTOMER EPA ID N0, <br /> l - �3y c <br /> PRODUCT WASTE MANIFEST <br /> CODE NUMBER QUANTITY. , fiVITS PRICE AMOUNT <br /> Used oil,Non-RCRA Hazardous Lubricating 10)ai5 c-• n"2:] Gah <br /> Waste,Liquid Industrial CA221 Gal. <br /> Used Autemot(re AnGfretu,Kon-RCRA Hawdous CA134 <br /> a�rau eta Gal. <br /> RQ K'asle Combestibra l.tgatd,K.OS.NA CA221 <br /> t9 ant O,contnminau,,withhalo^ces MIXON Gal. <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 SO/Specify Product Gal. <br /> Glycol Bul otte./Specify Product Gal. <br /> TEST:ffCl.r D Tech 40007 ppm []Clor D Tech 1000 Pass []Fail <br /> Retain sample#� Total Char es <br /> Required <br /> Field Service Work Description: <br /> Other: <br /> Other: <br /> 76E88�onr-it <br /> Consolidated Manifest DRIVER CHECKLIST <br /> Oil,Inc. � Evergreen Oil,Inc.-Davis❑Evergreen Oil,Inc.-Fresno r)Time hr Time Out <br /> mith Ave. Road 30B 4139 N.Valentine ❑lanllDrum Property Labeled <br /> Netvark,CA 94560 Davis,CA 95616 Fresno,CA 93722 P Y <br /> CAD980887418 CAD982446874 CAD982446882 ❑Accumulation Start Date Marked j <br /> -❑Evergreen E -"nv.Svc. kry mOd ir!"-S dMataria O House Keeping-Tank/Drum Clean i <br /> A6604-S.-San Pedro •745 A WestBettemvfa a - - --- -•••-••p Other Seri ices Checked:0Oil; Q'Pitters/Drums,'OAHtifreeze' <br /> 07 6 <br /> Carson,CA 9Santa Maria,CA 93454 p Called in other services needed❑Oil, Filters/Drums, Antifreeze <br /> i <br /> CAD9916964 CAD982446858 I <br /> Generator certifies that it has established a program to reduce the volume or <br /> Source: UrCollectiOn Station Q Govenlment quantity&toxicity of the hazardous tvaste to the degree determined by <br /> Q Marine Q Agricultural Q Industrial generator to be economically practicable. <br /> I hereby cgrtffy that I have read and have the authority to <br /> ]find the above listed generator to the terms on the reverse <br /> aide 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 /> Thes include more stringent leak detection and prevention requirements,engineering certifications Of ity,and financial assurances for <br /> clo a and accidental releases.It is lawful to send used oil to out-of-state facilities that comply onl eral used oil management standards <br /> an of these more stringent requirements.This notification is for information purposes only. <br /> river Signature rint Name Route# Vate era ature Print Name Date 1 <br /> White Copy=Customer Copy-Pink&Yellow Copy=Office Use•Green Copy=Attach to manifest-Golden Copy--Driver Copy <br />