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NAME �NAME WORK ORDER/SERVICE AGREEMENT Used oil, Non-RCRA Hazardous Lubricating Evergreen Envirc nental Services N 578838 ADD dedicated to the protection of the environment L1 r -O ATo schedule a pickup, call Send payment to: Sales Order # RQ Waste Combustible Liquid, N.O.S. NA 1993 111 Oil contaminated with halo ens) 800-596-9455 Evergreen Oil, Inc. CITY 6880 Smith Ave., Newark, CA EPA# CAD982413262 16540 S. San Pedro St., Carson, CA EPA# CAD982413262 Dept. LA 23234 Pasadena, CA 91185-3234 Date: GENERATOR/JOB LOCATION BILLING INFORMATION NAME �NAME immeapnplr�� Used oil, Non-RCRA Hazardous Lubricating (-:70 Gal. CASH F-1CHECK❑ # ADD CA221 L1 r ADDRESS CA 134 CUS TO 1 JODE NO. �l Y k�30r'3 RQ Waste Combustible Liquid, N.O.S. NA 1993 111 Oil contaminated with halo ens) STATE 7.11' CIA CO. CITY STATE ZIP CO. PO # P O ENO. ( Non Hazardous Water PHONE NO. ( ) PROFILE NO. CUSTOMER EPA ID NO. PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE CODE NUMBER AMOUNT Used oil, Non-RCRA Hazardous Lubricating CA221 Gal. Waste, Liquid Industrial CA221 Gal. Use Wastd Automotive Antifreeze, Non-RCRA Hazardous e Li uid CA 134 Gal. RQ Waste Combustible Liquid, N.O.S. NA 1993 111 Oil contaminated with halo ens) CA221 F001/F002 Gal. Oil & Water, Non-RCRA Hazardous Waste Liquid CA223 Gal. Non Hazardous Water Gal. Waste Solids and Sludges Gal. Wash Out Each Pressure Washer/Steam Cleaner Day Transportation Hrs. Fuel Surcharge % Glycol Bulk 50/50/Specify Product Gal. Glycol Bulk Conc./Specify Product Gal. TEST: ❑ Clor D Tech 4000 ppm ❑ Clor D Tech 1000 ❑ Pass ❑ Fail Retain sample- Required Total Charges Field Service Work Description: Other: Other: TSDF � Consolidated Manifest 1:1Evergreen Oil, Inc. Evergreen Oil, Inc. - Davis vergreen Oil, Inc. - Fresno 6880 Smith Ave. Road 30B 4139 N. Valentine Newark, CA 94560 Davis, CA 95616 Fresno, CA 93722 CAD980887418 CAD982446874 CAD982446882 ElEvergreen Env. Svc. [:]Evetglee %lm-SantaMalia❑ 16604 S. San 9gSan 745 A West Betteravia Carson, CA 907 Santa Maria, CA 93454 CAD9816964 CAD982446858 t� DRIVER CHECKLIST �me IrAr `B Time Out CilJ Tank/Drum Properly Labeled B Accumulation Start Date Marked use Keeping - Tank/Drum Clean Other Services Checked: ❑ Oil, ❑ Filters/Drums, ❑ Antifreeze ❑ Called in other services needed ❑ Oil, ❑ Filters/Drums, ❑ Antifreeze Generator certifies that it has established a program to reduce the volume or Source: Collection Station ❑ Government quantity & toxicity of the hazardous waste to the degree determined by ❑ Marine ❑ Agricultural ❑ Industrial generator to be economically practicable. Per Cal'a H. transpo d to a fa comply f ith the n oil are jtquired to I hereby certify that I have read and have the authority to bind the above listed generator to the terms on the reverse side of this form. IMPORTANT NOTICE REGARDING THE DISPOSITION OF YOUR OIL. and Safety Code Section 25250.9, Evergreen hereby advises customer tha customer's shipment of used oil may be that is required to comply with federal regulations applicable to manage t of used oil, t that is not required to tringent requirements applicable to hazardous waste management facil' es. alifornia f i 'es at handle or process used those more stringent requirements, and some out-of-state facilities th pr ess used s those requirements. agent leak detection and prevention requirements, engineering certif atio sof tank ' financial assurances for ses. Itis lawful to send used oil to out-of-state facilities that co ly my with f r use d it in standards en requirements. This notification is for information purposes o fi ¢,,,�o // n (/1 &'( XaA., Print Nalne Route # Date Ge�ir Signature Print Name Date