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• WORK ORDEARVICE AGREEMENT <br />i Evergreen Environmental Services N° 652402 <br />Jdedicated to the protection of the enoironment <br />To schedule a pickup, call Send payment to: Sales Order # <br />800-972-5284 Evergreen Oil, Inc. <br />6880 Smith Ave.. Newark, CA EPA# CAD982413262 Dept. LA 23234 ,O i s•� l Z <br />16540 S. San Pedro St.. Carson, CA EPA# CAD982413262 Pasadena, CA 91185-3234 Date: D <br />r,p,opto ATnotTnn r nVATTnIV RILLING INFORMATION <br />PRODUCT I WASTE I NUMBER MANIFEST I QUANTITY I UNITS I PRICE I AMOUNT <br />Used oil, Nan-RCRA Hazardous Lubricating <br />CA22 <br />NAME <br />Waste, Liquid Industrial <br />CASH ❑ CHECK ❑ <br />f <br />UW Aanm-Anifine NmRCRA Nna,dun <br />W uid <br />CA13 `r <br />Gal. <br />tMM 1..iM .hWwNA <br />cc <br />Gal. <br />Oil & Water, Non-RCRA Hazardous Waste Liquid <br />CA223 <br />8 <br />ADDRESS IF <br />ADDRESS <br />Waste Solids and Sludges <br />C CODE NO. <br />Z .So- r<f0 <br />Wash OutFath <br />Pressure Washer/StearnCleaner <br />CIT STA ZIP <br />CO. <br />CITY <br />STATE ZIP CO. <br />PO ff <br />HONE NO. <br />PHONE NO. <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />LQ 0 <br />PRODUCT I WASTE I NUMBER MANIFEST I QUANTITY I UNITS I PRICE I AMOUNT <br />Used oil, Nan-RCRA Hazardous Lubricating <br />CA22 <br />Gal. <br />Waste, Liquid Industrial <br />CA221c <br />Gal. <br />UW Aanm-Anifine NmRCRA Nna,dun <br />W uid <br />CA13 `r <br />Gal. <br />tMM 1..iM .hWwNA <br />moles <br />Gal. <br />Oil & Water, Non-RCRA Hazardous Waste Liquid <br />CA223 <br />Gal. <br />Non Hazardous Water <br />Gal. <br />Waste Solids and Sludges <br />Gal. <br />Wash OutFath <br />Pressure Washer/StearnCleaner <br />Day <br />Transportation Hrs. <br />Fuel Surcharge % <br />Glycol Bulk 50/50/Speeify Product Gat. <br />TEST: ❑ Clor D Tech 4000_—T.m ❑ Clm D Tech 1000 <br />Retain sample # <br />R / / ' ' L <br />PmTirpd <br />Consolidated Manifest <br />❑ Pau <br />Evergreen Oil, Inc. Evergreen oil, Inc. -Davis Evergreen Oil, lac. - Fresno <br />6880 Smith Ave. ❑ Road 30B ❑ 4139 N. Valentine <br />Newark CA 94560 Davis, CA 95616 Fresno, CA 93722 <br />CAD980887419 CAD982446874 CAD982446982 <br />Evergreen Env. Svc. lNummoklm-Santdaa� <br />16604 S. San Pedry1:1 745 A West Bettemvia <br />Carson, CA 90746 Santa Maria, CA 93454 <br />❑ Fail <br />Time En Time Out / <br />Tank/Drum Properly Labeled <br />Accumulation Stan Date Marked <br />House Keeping - Tank/Drum Clean <br />Other Services Checked: 0 Oil, 0 Filters/Drums, 0 Antifreeze <br />needed <br />CAD96169 CAD992446858 -- <br />Generator anifies that it has established a Program m reduce the volume w <br />Source: Fdf Collection Station ❑ Government quantity & toxicity of the hazardous waste to the degree determined by <br />Ll Marine Ll Agricultural ❑ Industrial gene ator to be economically practicable. <br />I hereby certify that I have read and have the authority to <br />bind the above li ted venerator to the terms on the reverse <br />side of this form. <br />IMPORTANT NOTICE REGARDING THE DISPOSITION OF YOUR OIL. <br />Per California Health and Safely 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 />comply with the more stringent requirements applicable to hazardous waste management facilities. California facilities that handle or process used <br />oil 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 finan ' assurances for <br />closu d accidental releases. It is lawful to send used oil to out-of-state facilities that comply only with federal use it agement standards <br />and n t se more stringent requirements. This notification is for information purposes only. <br />D ' ignature Print Name Route k Date Generator's gnat Print Name Date <br />whim r�mt=r.,: ' rwr Cnnv - Pink a yellow Coov=Office Use -Green Copy=Attach to manifest -Golden Copy=Dmrer Copy <br />