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174 WORK ORWERVICE AGREEMENT <br />4041 <br />'�Z' Evergreen Enionmental Services N-0 <br />dedicated to the prolection qfthe environment <br />To schedule a pickup, call Send payment to: <br />d <br />lip <br />800-596-9455 Evergreen 01r lli1c�.� <br />6880 Smith Ave., Newark, CA EPA# CAD982413262 P.O BOX 30$.1 <br />16540 S. San Pedro St., Carson, CA EPA# CAD982413262 Los An,eles, CA 9063b95 7 f <br />GENERATOR/,JOB LOCATION BILLING INFORMATION <br />0R <br />Sales Order # <br />L! <br />Date: "—<aP <br />NAME <br />NAME <br />CASH [] CHECK <br /># <br />AgDDRESS <br />ADDRESS <br />C[IS,TOMER CODE NO. <br />CITY STATE ZIP CO. CITY <br />w <br />STATE ZIP CO. <br />PO # <br />PHONE NO. <br />PHONE NO. <br />PROFILE NO. <br />CUSTOMER EPAIDNO. <br />P RODUCT <br />F- <br />WASTE <br />CODE <br />MANIFEST <br />NUMBER <br />QUANTITY UNITS PRICE <br />AMOUNT <br />Used oil, Non-RCRA Hazardous Luhriatting <br />CA?Ztr Gal. <br />c"> z*y <br />Waste, Liquid Industrial <br />CA221 <br />Gal. <br />LLsed Autnrmxiv A t rrce�c, Non-RCRA H;,.nduus <br />w:t,io r��t��d <br />CA134 r. t1':tir%,"" ;r';`;) Gat. <br />_ .-"S� <br />ra <br />RQ Waste Cnmbusiiblc LiyuiJ, N.O.S. NA <br />I993 ❑t IOiI conlantinuwd with h:duyeas) <br />CA_'� I <br />F000F00? <br />G31. <br />Oil& Water, Non-RCRA Hazardous Waste Liquid <br />CA221 <br />Gal. <br />Waste Solids and Sludges <br />Gal. <br />Wash Out <br />Each <br />Drained Used Oil Filters <br />Drum <br />Non-RCRA Hazardous Waste Solids (oily debris) <br />CA223 <br />Drum <br />Empty Drums <br />Drum <br />Transportation <br />Hrs. <br />Non Hazardous: Water <br />Gal. <br />Glycol Bulk ,' 50150 <br />Gal. <br />Glycol BuV Cone. <br />Gal. <br />TEST: O Clor D Tech 4000_�,, ppm ❑ Clor <br />D Tech IOOODPass ❑ Fail 0 Halogen Detector/Flame Test ❑ Pass ❑ Fail <br />T� , <br />Field Service Work Description: <br />Total Charges <br />Other: <br />Other: <br />Vacuum Services Time <br />Out of ftard On Site Off Site <br />Off Load Start�» <br />_4 —Off Load End Return to Yard <br />TSPF I I I Consolidated Manifest <br />Evergreen Oil, Inc. Evergreen Env. Svc. Evergreen Env. Svc. AJS Filter <br />6880 Smith Ave. Road 30B 4139W Valentine 1:115131 Clark Ave. <br />Newark, CA 94560 Davis, CA 95616 Fresno, CA 93722 Industry, CA 91745 <br />CAD980887418 CAD982446874 CAD982446882 CAD000097432 <br />EEvergreen Env. Svc. Evergreen Env. Svc. CFR CFR ❑ Greenleaf Env. Svc. <br />16604 S. San Pedro 745 A West Betteravia 944 E. Slauson Ave. 1:133210 Western 3474 Toyon Circle <br />Carson, CA 99746 Santa Maria, CA 93454 Los Angeles, CA 90011 Union City, CA 94587 Valley Springs, CA 95352 <br />CAD981696 -0 CAD982446858 CAL000110021 CAL000091507 CAL000214411 <br />Generator certifies that it has established a program to reduce the volume or <br />' <br />Source: Collection Station ® Government quantity & toxicity of the hazardous waste to the degree determined by <br />® Marine ® Agricultural ® Industrial generator to be economically practicable. <br />I hereby certify that I have read and have the authority to <br />bind the above listed generator to the terms on the reverse <br />Retain sample #� E F d. 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 />imply with the more stringent requirements applicable to hazardous waste management facilities. California facilities that handle or process used <br />1 are required to meet those more stringent requirements, and some out-of-state facilities that process used oil also meet those requirements. <br />��. These include more stringent leak detection and prevention requirements, engineering certifications of tank integrity, and financial assurances for <br />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 <br />and not these more stringent requirements. This notification is for information purposes only. <br />r)rivar ginnatm-a print ]Noma RnlltP if <br />