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• WORK ORDER/SERVVICE AGREEMENT
<br /> Evergreen Environmental Services N-0652538
<br /> dedicated to the protection of the e1wirolnnenl
<br /> OF To schedule a pickup,call Send payment to: Sales Order
<br /> 800-972-5284 Evergreen Oil,Inc.
<br /> 6880 Stnith Ave.,Newark,CA EPA#CAD982413262 Dept.LA 23234
<br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 Pasadena,CA 91185-3234 Date:!R9- 1S
<br /> GI;NERATOR/dOB LOCATION BILLING INFORMATION
<br /> 7E NAME CAS4 E]CHECK[]
<br /> ",r #
<br /> ADDRESS ADDRESS CU.T ill R CODE NO.
<br /> _ 006
<br /> CITY STATE ZIP CO. CITY STXrE ZIP CO. PO
<br /> PHONE NO, PHONE NO, PROFILE NO, CUSTOh7ER EPA ID Nf,.
<br /> PRODUCT IYASTE MANIFEST QUANTITY UNITS PRICE AMOUNT
<br /> CODE NUMBER
<br /> Used oil,Non-RCRA Hazardous Lubricating CA22 Gal,
<br /> Waste,Liquid Industrial CA221 Gal.
<br /> used AuwnwtiraAmiattu,NemRCWi naza,Jous
<br /> CA 134 Gal
<br /> Wsste LI uid
<br /> RQAasta Camixzc�lk LlquiJ,N.O.S,NA CA221
<br /> 199311[Oil coma.ninatzd,.ith hal ms) ro0jn02 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 /> TransportationHLs
<br /> Fuel Surcharge %
<br /> f Glycol Bulk 5015 Specify Product Gal.
<br /> Glycol Bulk oncJSpecify Product Gal,
<br /> TEST: Clor D Tech 4000?�ppn1 Clor D Tech 1000 Pass Fail
<br /> Ref gillsample# � � � � Total Char es
<br /> Required
<br /> Field Service Work Description:
<br /> Other:
<br /> Other:
<br /> VT,8D Consolidated Manifest DRIVE
<br /> Oil,Inc. ❑ Evergreen Oil,Inc.-Dabs❑Evergreen Oil,Inc,-Fresno ❑Time ITime Out
<br /> mith Ave. Road 30B 4139 N•Valentine
<br /> Newark,CA 94560 Davis,CA 95616 Fresno,CA 93722 ❑Tinrk/Drum Properly Labeled
<br /> CAD980887418 CAD982446874 CAD982446982 ❑ Accumulation Strut Date Ntarked
<br /> Evergreen Env.Svc. D mt?J lna-SarvaAla a ❑House Keeping-Tank/Drum Clears
<br /> ca
<br /> '16604'S.'SanPed ... 745A\YestBetfeiaa
<br /> Carson,CA 907 Santa Maria CA 93454
<br /> 001 Services Checked:❑Oil, ❑ Filters/Drums,❑Antifreeze
<br /> CAD981696 CAD982446858 ❑Called in other services needed❑Oil, ❑ Filters/Drums,❑Antifreeze
<br /> Generator certifies that it has established a program to reduce the volume or
<br /> SOUI'Ce; Collection Stati0ii Q Govemlrleut quantity&toxicity of the hazardous waste to the degree determined by
<br /> Q Matins Q Agricultural ® Industrial generator to be economicatiy practicable.
<br /> I hereby certify that I have read anti have fire authority to
<br /> hied 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 /> 'omply with the more stringent requirements applicable to hazardous waste management facilities.California fac ties that handle or process used
<br /> t I are required to meet those more stringent requirements,and some out-of-state facilities that process used o• Is meet those re uirements.
<br /> I'hese include more stringent leak detection and prevention requirements,engineering certifications oft nk i egr y, finance ances for
<br /> closur nd accidental releases.It is lawful to send used oil.to out-of-state facilities that comply only th fe r u oil agement standards
<br /> and t tress more s,tringentrequirements-Thin«notification is for information purposes only.
<br /> D ver Signature Print Name Route# Date Generator's Sign re Print Name Date
<br /> White Canv=Customar QOnv-Pink A Yallnw rnnv_nffira 1 Ica-Gtroan r:nnv–Aft—h in—nir—t_r_„1.L„n r nn, n,:,,.,,r,—, I
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