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WORK ORDER/SERVICE AGREEMENT <br /> Evergreen Environmental Services N° 692-959 <br /> dedkoted to the protection of the enrhonraent <br /> To schedule a pickup,call Send payment to: Sales Order# Z <br /> 800-972-5284 Evergreen Oil,Inc. <br /> 6880 Sntith Ave.,Newark,CA EPA#CAD982413262 Dept.LA 23234 1 <br /> 16540S.San Pedro St.,Carson,CA EPA#CAD982413262 Pasadena,CA 91185-3234 Date: <br /> GENERATOR/30B LOCATION BILLING INFORMATION <br /> ME A NAME CASHE]CHECK F1vw tt+✓y fIcSNG r # <br /> ADDRESS ADDRESS CUSTOMER CODE NO. <br /> a Cr Hm W 4o, ,5-- A <.-,cAg <br /> TTY STATE ZIP CO. CITY STATE ZIP CO. PO# <br /> Zv�S" <br /> PHONENO. PHONENO. PROFILE NO. CUSTONIEREPAIDNO. <br /> 16 • Ci <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> Used oil,Nan-RCRA Hazardous Lubricating CA221 Gal, <br /> Waste,Liquid Industrial CA221 Gal. <br /> Used Amemave Antlfreaze,Noy-RCRA Huatdws CA134 Gal. <br /> RQ Waste Cumtustibla l.iquFd,N.OS.NA CA2W2 21 Ga) <br /> 1993111 oiltontrminacdKithhalo=ens fWIA <br /> Oil&Nater,Non-RCRA Hazardous Waste Liquid CA223 Gal, <br /> Non Hazardous Water Gal. <br /> Waste Solids and Sludges Gal. <br /> Nash Out Each <br /> Pressure Washer/Steam Cleaner Day <br /> Transportation MS. <br /> Fuel Surcharge % <br /> i. Glycol Bulk 50/50/Specify Product Gal. <br /> Glycol Bulk oncdSpecifyProduct yGal. <br /> TEST: . Cloy D'&,h 400029-0ppm E]Ctor D Tech 1000 Pass ❑Fail <br /> Retails sample# ' Total Charges <br /> Re uired <br /> Field Service Work Description: i <br /> Other: 1 <br /> Other: <br /> TS Consolidated Manifest DRIVE CHECKLIST <br /> Evergceea Oil,Inc. Evergreen Oil,Inc.-Davis❑Evergreen Oil,Inc.-Fresno El Time In Time Out <br /> 6Mg8 ' <br /> 80 Smith Ave. Road 30B 4139 N.Valentine ❑TnitktT)rum Properly Labeled <br /> Newark,CA 94560 Davis,CA 95616 Fresno,CA 93722 y <br /> CAD980887418 CAD982446874 CAD982446882 ❑Accumulation Start Date Marked <br /> l—t Evergreen Env.Svc. F1 Ql Inc•Svrlast� ❑House Keeping-Tanl✓Dront Clean <br /> ..,_......................._.............._.....166045.SanP.edro...........74 Vest.aetteray.ia..... ❑.Other Services.Checked:.13.911,_13. <br /> Carson,CA 9070 Santa Maria, 93454 <br /> CAD981696 CAD982446858 p Called in other services needed [I Oil, ❑ Filters/Drums, Antifreeze <br /> i 58 <br /> Generator certifies that it has established a program to reduce the volume or j <br /> Source: Collection Station ®GovenunI hereby certify that I have read and have the autboritx to <br /> ent quantity&toxicity of the hazardous waste to the degree determined by <br /> El Marine C3Aglieultulal ®Industrial generator to be economically practicable. <br /> bind 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 /> ` oil are required to meet those more stringent requirements,and some Rut-of-state facilities that process used oil ass eet those requirements. <br /> Theso include more stringent leak detection and prevention requirements,engineering certifications o tank inte y, td financial assurances for i <br /> :>losu and accidental releases.It is lawful to send used oil to out-of-state facilities that contpIy ons with feder us oil management standards <br /> these more stringent requirements.This notification is for information purposes only. , <br /> r Signature Print Name Route# Datenerator's Sig Print Name Date <br /> White Copy=Customer Copy-Pink&Yellow Copy=011ice Use-Green Copy=Attach to ifest-Golden Copy=Driver Copy <br />