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O�IAME Y� t1f2 ,, Zr WORK ORDEP /SERVICE AGREEMENT CASH ❑ CHECK ❑ # Evergreen Envirc .Mental Services N 580448 4—.0, dedicated to the protection of the environment To schedule a pickup, call Send payment to: -O �-J PO # r ' to Gal. Sales Order # ,L,.% PHO NO. 800-596-9455 Evergreen Oil, Inc. CUSTOMER EPAID NO. 6880 Smith Ave., Newark, CA EPA# CAD982413262 16540 S. San Pedro St., Carson, CA EPA# CAD982413262 Dept. LA 23234 Pasadena, CA 91185-3234 Date: (AD — Z i 112 GENERATOR/JOB LOCATION BILLING INFORMATION O�IAME Y� t1f2 ,, Zr NAME CASH ❑ CHECK ❑ # ADDRESS tv, .5-j— ADDRESS TOMER CODE NO. V Z C Y STATE ZIP CO. CITY STATE ZIP CO. PO # r ' to Gal. RQ Waste Combustible Liquid, N.O.S. NA 1993 In (Oil contaminated with halogens) PHO NO. PHONE NO. PROFILE NO. CUSTOMER EPAID NO. PRODUCT WASTE MANIFEST CODE NUMBER QUANTITY UNITS PRICE AMOUNT Used oil, Non-RCRA Hazardous Lubricating CA221 (y �J�'% Gal. Waste, Liquid Industrial CA221 Gal. Used Automotive Antifreeze, Non-RCRA Hazardous Waste Li uid CA 134 Gal. RQ Waste Combustible Liquid, N.O.S. NA 1993 In (Oil contaminated with halogens) CA221 MUM 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/Specify Product Gal. Glycol Bul ConcJSpecify Product Gal. TEST: 11 Clor D Tech 40 ppm ❑ Clor D Tech 1000 Pass ❑ Fail Retain Sample # Required I .p <-- Total Chare Field Service Work Description: Other: Other: 1 TSD [/7 Consolidated Manifest DRIVE CHECKLIST Evergreen Oil, Inc. ❑ Evergreen Oil, Inc. - Davis ❑ Evergreen Oil, Inc. -Fresno p Time In Time Out 6880 Smith Ave. Road 30B 4139 N. Valentine Newark, CA 94560 Davis, CA 95616 Fresno, CA 93722 ❑ Tank/Drum Properly Labeled CAD980887418 e, CAD982446874 CAD982446882 ❑ Accumulation Start Date Marked ❑Evergreen Env. Svc. ❑ E�egre %fir.-S=Matia❑ 16604 S. San Pe 745 A West Betteravia Carson, CA 90746 Santa Maria, CA 93454 CAD98169642f CAD982446858 Source: ❑'Collection Station ❑ Government ❑ Marine ❑ Agricultural ❑ Industrial House Keeping - Tank/Drum Clean Other Services Checked: ❑ Oil, ❑ Filters/Drums, ❑ Antifreeze 0 — 10 Called in other services needed ❑ Oil, ❑ Filters/Drums, ❑ Antifreeze Generator certifies that it has established a program to reduce the volume or quantity & toxicity of the hazardous waste to the degree determined by generator to be economically practicable. I hereby certify that I have read and have the authority to bind the above listed venerator to the terms on the reverse 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 cloe and accidental releases. It is lawful to send used oil to out-of-state facilities that comply only with federal oil anagement standards an n t these more stringent requirements. This notification is for information purposes only. '07/j D ' er Signature Print Name Route # Date nerator's Signature PrintName Date