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05/23/2011 HON 15: 54 FAX 209 467 1126 Blackmun Equipment 2009/029 <br /> WORK ORDToERVICE AGREEMENT <br /> Evergreen Envirnmental Services ego E 7 1 <br /> dedh ared ro rife pmtrcriun of rhe envimnmenr <br /> To schedule a pickup, call Send payment to: Sales Order # _ <br /> 800-596-9455 Evergreen oil.Inc. <br /> 69W Smith Ave..Newvrk,CA EPA#CAl)9a2413262 Dept-LA 23234 r <br /> 16540 S.San 0.,1m St..Camna,CA EW CAD987A 13267 Pasadena.CA 91185-3234 Date: <br /> GF.NF.RATOR/JOB T OCA ION BTI.T.TNG INFORMATION <br /> � �— <br /> NAME - CASH r]CHECK[� <br /> ADD 9 ADDIiE55 CUS 't CODE N0. <br /> s <br /> C STATE. ZIP CO. CII'Y STATE ZIP CO. M)# <br /> PHONE:N'�.. L- PHONE NO. PROFU R NO. CUSTOMER EPA m NO. <br /> PRODUCT WASTE. MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE N17MRER <br /> Uscd oil.Non-RCRA Hazardous Lubricating _ CA2 Gal. <br /> Wssto,l,igntd industrial CA221 Gal. <br /> VW AVwmprvc AVNrear_NrrnnClN lluaNm I ^ <br /> wi4lf lir ni,l CAt �` GaL <br /> aVW"• CarrWnW�bk[.qwa,N.0.ti.NA (:A]?7 <br /> i 199]al On canmmr,rurul.ab lydV m NUIn110. Gal. <br /> Oil dr .Wruer,Non-RCRA Hazanku Waste Liquid CA223 Gal. <br /> Nom Hararcious Water Cal. <br /> Waste Solids mad sludges Gal. <br /> Wish Out Each <br /> Pressure Washer/Steam Cleaner Day <br /> Traospun:aitm Hrs. <br /> ]vel Surcharge % <br /> Olycol Bulk 50 SpeciTy Product Cwt, <br /> Glycol➢ul onc./Spocify PProdwt Gal. <br /> 'PEST.2f Clot D Tech 40N2-..!�ppm ❑Clor D Tech 1000 ❑I$ee ❑Pull <br /> Retain sample# - Total es <br /> Re uired r� —41-)e! . , <br /> Field Service Wnrk Descrip6m: <br /> Other: <br /> ()Ther. <br /> TSD Consolidated Manifest DRIVE, t CKLIST ' <br /> Evergreea Oil,Inc. Evcgmrn oil,Inc,-Davis L`vcrgrcenChl.Inc.-h'reano <br /> El ❑ Twa ham. lulus Om <br /> KR80 Smith Ave. Road 30➢ 4139 N.Valcntice ❑Tan]JDrum Properly Labeled <br /> Newark,CA 94560 Davis,CA 95616 Ft w,CA 93722 per'Y <br /> CAD980887418 CAD982446874 C1AD982446882 ❑ Accumulation Start Date Marked <br /> Evcrgrcen Fay.Sw. EuagtonOlkt:SwaaMvtt ❑ Hmtgc.ICerping-Tank/Drnm Cleat <br /> 16604 S.San Pcd 745 A West Bdteraviu ❑ ❑ Other Sluices Cheekcd: Cl Oil, ❑ Filrcra/Omrtls. O Antiifrectt <br /> Carsuar CA 907 Status Maris,CA 93454 <br /> CAO98169 CAD982446R58 ❑ Called in other services needed Cl OD. fltendlhamc,rl AuiGecee <br /> Source: Collection Station El Govmiment Generator seri fiec that it has established a progrmn 10 reduce Lhc volume or <br /> quantity&tuxicity of the hazardous www to the degree determined by <br /> 0 Maine U Agricultural U Industrial Fcnamtor to be actmamically practicable. r <br /> IJterebv CCI'[dry that I have read <br /> -and-have the authority to <br /> hind the_above li4tcd eearrator to the terms as the reverse <br /> Side nr Ibis rurm, r <br /> 11MPORTANT NOTICE REGARDING THE DISPOSITION OF YOUR OIL. <br /> Per California Health and Safely Code Section 25750.9,Evargrmn hereby advises customer that customers shipment of used oil may be <br /> transpurtcd to a facility that is required lu comply with federal regulations applicable to management of used oil,but Ihat is not required W <br /> comply with the more stringent retryircmenrs applicable to hazardous waste m magemcn(facilities.Clali fortda 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 most those requirements. <br /> These include mom stringent leak dctccrion and prevention requirements.engineering catiGcations or tank intcgdty,and financitd assumnrec for <br /> do and accidenla]mlcases.Itis lawful to send used oil to outof-stale GvciEtics that comply only with federal used oil management standards <br /> an n t these mtmc string t rcyuircmentc-Tlhis notification is for informaton purposes only. <br /> LrSignature Print Name Route# Date Generator's Ignature Print Name Date <br /> White Copy=Customer Copy-Pink&Yellow Copy=Ofhce Use•Green Copy--Attach to manifest-Golden Copy--Driver Copy <br />