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0 <br /> WORK®RDEA R/SERVICE AGREEMENT <br /> Evergreen Environmental Services <br /> dedicated to the protection of Me envianiment NO (3 2 3 1 3 3 <br /> To schedule a pickup,call Send paymlent to: Sales Older#1 - ✓ <br /> 800-596-9455 Evergreen Oil,Inc. <br /> 1 6880 Smith Ave..Newark,CA EPAI/CAD982413262 Dept.LA 23234 <br /> 16540 S.San Pedro•St.,Carson,CA EPA/I CAD982413262 Pasadena,CA 91185-3234 Date: �r�� c, •_i'i <br /> GENERATOR/JOB LOCATION BILLING INFOR)IATION <br /> ME c r NAME <br /> nE, <br /> ADDRESS <br /> /� ® �-. ADDRESS <br /> CIT Gw STATE ZIP CO. CITY STATE ZIP CO,PHONENO• PHONE NO. PROMLE NO. <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> Used oil,Non-RCRA Hazardous Lubricating CA22 )17 jf Gal. <br /> Waste,Liquid Industrial CA221 Gal. <br /> Used Amoir"'ic Andfrom,Non-RCRA Ha—duus <br /> \Paste Li n)d CA134 Gal. <br /> RQ\5'n,te Comlvstibk Liquid,N,O.S.NA CA?21 <br /> r99311r Oli e�ntamin3[ed ivitA hsioens) Po61/F002 Gal, <br /> Oil&Water,Non-RCRA Hazardous Waste Liquid CA223 Gal. <br /> Non Hnzardous Nater Gal. <br /> Waste Solids and Sludges Gal. <br /> Nash Out <br /> Each <br /> Pressure Hasher/Stena)Cleaner Day <br /> Transportation Hrs. <br /> Fuel Surcharge % <br /> Glycol Bulk 5 01Specify Product Gal. <br /> Glycol Bul}• oncBpecify Product Gal, <br /> TEST: Clor D Tech 40001j=tppm ❑Cldr D Tech 1000 Pass []Fail <br /> Retain sam l ale# <br /> Re Hired + Total Char es i <br /> Field Service Work Description: <br /> Other: <br /> i <br /> Other: <br /> LJ <br /> TSV Consolidated Manifest DRIVER CHL ST <br /> Evergreen Oil,Inc. Evergreen Oil,Ine.-Davis Evergreen Oil,Inc.-Fresno 11 Time]n �- <br /> 6880 Smith Ave. ❑ Road 30B ❑4139 N.Valentine Time Out <br /> Newark,CA 94560 Davis,CA 95616 Fresno,CA 93722 ❑TbnidDnnn Properly Labeled <br /> CAD980887418 CAD982446874 CAD982446382 ❑Accumulation Stan Date,4larked <br /> Evergreen Bnv.Svc. Eltxgms)A1 b�-SanA4D House Keeping-Thnk/Drunl Clean <br /> J6604S.San Ped r --❑-745ArlestBetteravinQ. <br /> Carson,CA 907 Santa Maria,CA 93454 O Other Services Checked:❑Oil;'0 Fihets(Dranis;b Antifreeze-- " <br /> CAD98I6964 CAD982446858 0 Called in other services needed Ij Oil, t7 Fil(ers/Drums,_Q Antifreeze <br /> SOtll'CO: COlieCtlOn Station (i0Ve1T1111ent Generator certifies that it has established a program to reduce the volume or <br /> quantity&toxicity of the hazardous waste 19 the degree determined by <br /> ®Marine Q Agl-cultural Q Industrial generator to be economicntly practicable. <br /> X hereby certify that I have rend and have theauthority to <br /> brad the aboveI'Sted g re re►afor to the terms on the reverse <br /> side of this fora) <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(hat is required to comply with federal regulations applicable to management of used oil,but that is not required to <br /> ,ontply with the more stringent requirements applicable to hazardous waste management facilities.California facilities that handle or process used <br /> t l are required to meet those more stringent requirements,and some out-of-state facilities that process used oil also meet those requirements, <br /> l'It include more stringent leak detection and prevention requirements,engineering certifications of tank integrity,and financial assurances for <br /> Clos a and accidental releases.It is lawful to send used oil to out-of-state facilitie. rat comply only with federal used oil management standards <br /> anj1heSe more stringent uiremenls.This notification is for information pu ilyIA Signature •int Name Route# Date is Signature Print Name Date <br /> White Copy=Customer Copy-Pink g Yellow COpV=Office Use•Green Con -Attach to manifast.t;oldan Cnnv=niivA.r r:nnv i <br />