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f WORK O R/SE VICE AGREEMENT Evergreen Environmental Services J dedicated to the protection of the environmentNo 4 417 To schedule a pickup, call Send payment to: Sales Order # ,_ 800-596-9455 Evergreen Oil, Inc. 6880 Smith Ave., Newark, CA EPA# CAD982413262 P.O. BOX 30517 SEP 16540 S. San Pedro St., Carson, CA EPA# CAD982413262 Los Angeles, CA 90030-0517 Date: GENERATOR/JOB LOCATION BILLING INF0RN4AT aIaa%=Kq-rA1 HEAl NAME ADDRESS NAME �T( ADDRESS CASH El CHECK ❑ CUSTOMER CODE NO. r, CITY STATE ZIP CO. CITY STATE ZIP CO. PO # PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE CODE NUMBER AMOUNT Used oil, Non-RCRA Hazardous Lubricating CA221 ._ `+ ' a;', '%(_� Gal. Waste, Liquid Industrial CA221 Gal. Used Automotive Antifreeze. Non-RCRA Hazardous - Gal. Waste Li ,,d CA134 RQ Waste Combustible Liquid, N.O.S. NA CA221 1993 III Oil contaminated with halogens) FooltFo02 Gal. Oil & Water, Non-RCRA Hazardous Waste Liquid CA221 Gal. Waste Solids and Sludges Gal Wash Out Each Drained Used Oil Filters Drum Non-RCRA Hazardous Was Solids (oily debris) CA223 Drum Empty Drums Drum Transportation Hrs. Non Hazardous. Water Gal Glycol Bulk 50150 Gal. Glycol Bulk Conc. Gal TEST: ❑ Clor D Tech 4000 - ppm ❑ Clor D Tech 1000 ❑ Pass ❑ Fail ❑ Halogen Detector/Flame Test ❑ Pass ❑ Fail Field Service Work Description: Total Chargaes Other: Other: Vacuum Services Time -.--. Out of Yard On Site Off Site Off Load Start Off Load End Return to Yazd TSDF Evergreen Oil, Inc. 6880 Smith Ave. --Newark, CA 94560 CAD980887418 ❑ Consolidated Manifest ❑ Ave Evergreen Env. Svc. ❑ Evergreen Env. Svc. ❑ AJS Filter ElRoad 30B 4139 N. Valentine 15131 Clark. Davis, CA 95616 Fresno, CA 93722 Industry, CA 91745 CAD982446874 CAD982446882 CAD000097432 ❑ Evergreen Env. Svc. ❑ Evergreen Env. Svc. ❑ CFR ❑ CFR ❑ Greenleaf Env. Svc. 16604 S. San Pedro 745 A West Betteravia 944 E. Slauson Ave. 33210 Western 3474 Toyon Circle Carson, CA 90746 Santa Maria, CA 93454 Los Angeles, CA 90011 Union City, CA 94587 Valley Springs, CA 95352 CAD981696420 CAD982446858 CAL000110021 CAL000091507 CAL000214411 Source: ®Collection Station ❑Government Generator certifies that it has established a program to reduce the volume or quantity & toxicity of the hazardous waste to the degree determined by LlMarine L)Agricultural LlIndustrial generator to be economically practicable. I hereby certify that I have read and have the authority to bind the above listed generator to the terms on the reverse Retails Sample # side of this form. IMPORTANT NOTICE REGARDING THE DISPOSITION OF YOUR OIL. Per California Health and Safety Code Section 25250.9, Evergreen hereby advises customer that customer's shipment of used oil may be transported to a 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 management facilities. California facilities that handle or process used oil are required to meet those more stringent requirements, and some out-of-state facilities that process used oil also meet those requirements. These include more stringent leak detection and prevention requirements, engineering certifications of tank integrity, and financial assurances for closure and accidental releases. It is lawful to send used oil to out-of-state facilities that comply only with federal used oil management standards and not these more stringent requirements. This notification is for information purposes -,only.