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a ' Ad, WORK ORDER/SERVICE AGREEMENT 4Evergreen Environmental Services N® 600585 w dedicated to the protection of the envirzntniew jj To schedule a pickup,call Send payment to: Sales Order# 800-596-9455 Evergreen Oil,file, 6880 Sin ith Ave.,Ncamrk,CA EPA/t CAD982413262 Dept.LA 23234 16540 S.San Pedro S!.,Carson,CA EPA#CAD982413262 Pasadena,CA 91185-3234 Date: GI;NERATOR/1013 LOCATION BILLING INFORMATION 3E NAME CASH Q CHECI((� DRESS r A RE.SS # a4a, Apo# ER CODE NO. CIT_ STATE ZtP O. CI'T'Y STA'1•E ZIP CO. t`1 CA PRONE NO. _ PHONE NO. I PROTILE NO. CUSTONIER--EPA NO, PRODUCT WASTE MANIFEST CODE NUNIBER QUANTITY UNITS PRICK AMOUNT Used oil,Non-RCRA Hazardous Lubricating CA22 Gal. Waste,Liquid industrial CA221 Gal. Uud Automu!i�t wane Li Anlifrtze,\qi-11CRA 1{vanlous CA134 Id Gal. RQ\{'k comb kib!zLlquiJ,N.f).S,YA CA221 1991 tl!Oil enoWminsed uiih halo^em F'001/f0o2 Gal. Oil&Water,Non-RCRA Hazardous Waste Liquid CA223 Gal Non Hazardous\Vater Gal, Waste Solids and Sludges l, Ga Wash Out Gal, Pressure WasherlStean)Cleaner Day Transportation Fuel Surcharge % Glycol Bulk 50/ pecify Product Gal. ! i Olycol But• oncJSpecify Product— Gal. i TEST: Clor D Tech 41X30 _ppIn ❑Clor D Tech 1000 Pass []Fait Retain sample# Total Charges Re hired � Field Service Work Description: Other: Other: TS A Consolidated Manifest Evergreen Oil,Inc. DRIVER CHECKLIS F-1Evergreen Oil,hie,-Davis❑Evergreen Oil,Inc.-Fresno O 1 ane In 6880 Smith Ave, Road 30B 4139 N.Valentine Tinto Out Newark,CA 94560 Davis,CA 95616 Fresno,CA 93722 El Tank/Drum Properly Labeled CAD980887418 CAD982446874 CAD982446882 ) ❑Accumulation Start Date\•inrked ❑ Evergreen Env.Svc ❑ Eterpm0,��,- ,%L ❑ House Keeping-Tank/Drum Cletus 16rso ,- San Pe Sana745 A West;CA9 45 ❑ ❑OtlierServicesChecked:❑OilCl.Filters/Drums,❑Antifreeze..... i ..........................._Casson,CA 90 ................Sputa Maria:CA 93454.. .. ........... ............ .......... ... ..... CAD981696 0 CAD982446858 10 Called in other services needed ❑oil, ❑FilterdDrums,❑Antifreeze r quantity&:toxicity of the hazardous waste to the degree determined by Source: C011eet1011 Statioll ®Government Generator certifies that it has established a program to reduce the Mance or j ®Marine ® Agricultural ®Indusbial generator to beecononticallypracticable. I hereby certify that I have read and have the aufhor ityto bind the above listed generator to the scups on tl► ---se side of this form, J IMPORTANT NOTICE REGARDING THE DISPOSITION OF YOUR OIL. Per California Health and Safety Code Section 252509,Evergreen hereby advises customer that custonier's shipment of used oil rorty be transported to,'facility that is required to comply with federal regulations applicable to management of used oil,but that is not required to comply with the more stringent requirements applicable to hazardous waste nlanagemenffaeilities.California facilities that handle or process used oil ar equired to meet those more stringent requirements,and sonic out-of-state facilities that process used oil also meet those requirements. The e i elude more stringent leak detection and prevention requirements,engineering certifications of tank integrity,and financial assurances for 1 Flo tie and accidental releases.It is lawful to send used oil to out-o€--state facilities that Comply only with federal used oil management standards ane no these more stringent r quirements.This notification is for information purposes only. a� p � l t1 o• t Il D .'ver Signature Print Name Route# Date operator's Sign re nt Name Date ` White Copy-Customer Copy-Pink&Yellow Copy=0lfice Use-Green Coov=Attach to manifest-Golden Conv=Drivrtr Cnnv I