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WORK ORDER/SERVICE AGREEMM1rKNT <br /> vergreen Environmental Services <br /> dedicatert to file protection of the environment N A 636415 <br /> To schedule a pickup,call Send payment to: <br /> _ Sates order <br /> 800-596-9455 # /s t <br /> Evergreen Oil,Inc. <br /> 6880 Smith Ave%Newark,CA EPA#CAD982413262 Dept.LA 23234 <br /> 16540 S.San Pedro St.,Carson,CA EFA#CAD982413262 Pasadena,CA 91185-3234 �.� <br /> GENERATOR/JOB LOCATION Date:—Lt <br /> t BILLING INFORMATION ;,- <br /> I r NAME <br /> CASITCIIGCK <br /> ADDRESS � �`� <br /> ADDRESS CUSTOMER CODE NO f' <br /> CIT STATE ZIP CO, CITY STATE <br /> �` Z.7 rZIP CO, PO# <br /> PHONE NO, <br /> PHONE NO, PROFILE NO, C STOMER EPA ID NO. <br /> c r <br /> PRODUCT WASTE MANIFEST <br /> CODE NUAIBER QUANTITY UNITS PRICE AMOUNT <br /> Used oil,Not)-RCRA Hazardous Lubricating CA22 <br /> Waste,Liquid Industrial CA22I <br /> USCdAVtomolh'e Anlirrora.Nm-RCRA M2.dous <br /> %N.ta u std CA134 Gal <br /> R414. Combustfile Lf-16,N.O.S.NA CA22I <br /> 19/93111 ORe uminattd with halo•trs) FkA21 02 Gal. , <br /> Oil&Water,Non-RCRA Hazardous Waste Liquid CA223 <br /> Gal. i <br /> Non Hazardous Water <br /> Gal. <br /> Waste Solids and Sludges <br /> Gal. <br /> Wash Out Each <br /> Pressure\Masher/Steam Cleaner <br /> Day <br /> Transportation <br /> Hrs. <br /> Fuel Surcharge % <br /> 1, Glycol Bulk 50/ Specify Product <br /> Gal. <br /> Glycol Bulk oncJSpecify Product <br /> y Gal. 1 <br /> TEST: Clor D Tech 400& ppm []Clor D Tech 1000 Pass <br /> Fail i <br /> Refain Sample Total Char es <br /> Re Hired <br /> Field Service Work Description: } <br /> Other: <br /> Other. <br /> TS Z r <br /> Consolidated Manifest DRIV CHECKLIST <br /> Evergreen Oil,Inc. EvergrtanOil,Inc.-Davisa MvrgreenOil,Inc.-Fresno <br /> 6880 Smith Ave. ❑ Road 30B 4139 N.Valentine O Time hi.' Time 01u <br /> Newark,CA 94560 Davis,CA 95616 Fresno,CA 93722 D Tank/Druni Properly Labeled <br /> CAD980887418 CAD982446874 CAD982446982 <br /> D Accumulation Start Date Marked <br /> ❑ Evergreen Env Svc a an Glc•-Sartamah D House Keeping-Tank/Ulvm Clean <br /> 16604 S.San Pe ❑ 74 West Betteravia ❑ <br /> ...........•-.-- Carson,CA-90 - - -• •Santa Maria;CA 93454— .- - 0 Other Services Cli k-ed:,El,0il,.to.Filters/Druins,17 Anlifreeze-..... . <br /> CAD98169 0 CAD982446858 D Called in other services needed p Oil, D Filters/Drums,0 Antifreeze s <br /> Source: Collection Station ®Govemnlent Generttorcenities that it has established a program to reduce the volume or <br /> quantity&toxicity of the hazardous waste to the degree determined by <br /> (-I Matin U Agueultural ®Indusbial generator to be economically practicable. <br /> I ter r if that have realtArld Iia (lie aulljL)rjly to <br /> bindtl_ to above list <br /> �get.arnr^*to the terms On the revers j <br /> side of this forin <br /> IMPORTANT NOTICE REGARDING THE DISPOSITION OF YO1VR OIL, i <br /> Per California Health and Safety Code Section 25250.91 Evergreen hereby advises customer that custotji is shipment of used oil may be i <br /> transported to a facility that is required to comply with federal regulations applicable to management of ppied oil,but that is not required to { <br /> ('ompl' ith the more stringent requirements applicable to hazardous waste management facilities.California facilities.that handle or process used <br /> ( 1 areA, quired to meet those more stringent requirements,and soma out-of-state facilities that process tised oil also meet those requirements. <br /> rhes 'i elude more stringent leak detection and prevention requirements,engineering certifications of tank integrity,and financial assurances for i <br /> clos and accidental releases.It is lawful to send used oil to out-of-state facilities that comply only with federal used oil management standards <br /> and these more stria nt requirements.This notification is for hiformation purposes only, <br /> `river Signature Print Name Route# Date Genera is Signature. Print Name Date <br /> White Copy=Customer Copy•Pink&Yellow Copy=Otlice Use-Green Copv=Attach to manifest-Golden Coov=Driver Conv <br />