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WORK ORDER/SERVICE AGREEMENT <br />Evergreen Envir�Illental Services N° 549433 <br />01 dedicated to the yroteTron of the environment <br />To schedule a pickup, call Send payment to: Sales Order # J&gZ.14;j- <br />800-596-9455 Evergreen Oil, Inc. <br />6880 Smith Ave., Newark, CA EPA# CAD982413262 Kept. LA 23234 w <br />16540S. San Pedro SL, Carson, CA EPA# CAD982413262 Pasadena, CA 91185-3234 Date: <br />GENERATOR/JOB LOCATION BILLING INFORMATION <br />MEA )f <br />MA -4b <br />VV� <br />NAME <br />CASH [] CHECK <br />N <br />RES, <br />ADDRESS <br />CUSTOMER ODE NO. <br />W vqo i <br />CITY STATE ZIP CO. <br />CITY STATE ZIP CO. <br /># <br />P110 E zif l 4'I � _ 4 � <br />L..S 7 <br />PHONE NO. <br />PROFILE NO. <br />CUSTAM` �l'�1� N0. <br />((�-AMOUNT <br />PRODUCT WASTE <br />CODE <br />MANIFEST QUANTITY <br />NUMBER <br />UNITS PRICE <br />Used oil, Non-RCRA Hazardous Lubricating CA2 <br />Gal. <br />Waste, Liquid Industrial CA221 <br />Gal. <br />Usea Automotive Amirrtem, Nnn-RCRA Harurdous CA134 <br />w�mu a;a <br />Gal. <br />RQ Waste Combuvible Liquid, N.O.S. NA CA221 <br />1993 In(Oii conemmamd with holo ensI Fllel/mo2 <br />Gal. <br />Oil & Water, Non-RCRA Hazardous Waste Liquid CA223 <br />Gal. <br />Non Hazardous Water <br />- <br />Gal. <br />Waste Solids and Sludges <br />Gal, <br />Wash Out <br />Each <br />Pressure Washer/Steam Cleaner <br />Day <br />Transportation <br />Hrs. <br />Fuel Surcharge <br />rye <br />Glycol Bulk 5/ -",Specify Product <br />Gal. <br />Glycol But one./Specify Product <br />Gal. <br />� <br />TEST: Clor D Tech 4000Jc pppm E] Clor D Tech 1000[faas <br />E] Fail E] Pass [-] Fail <br />Retain sample # <br />Required I C� <br />Total Charges <br />Field Service Work Description: <br />Other: <br />Other: <br />TS IJJ [jF Consolidated Manifest <br />FJ•/Evergreen Oil, Inc. Evergreen OR, Inc. -DavisEvergreen Oil, Inc. - Fresno <br />6880 Smith Ave. ❑ Road 30B ❑ 4139 N. Valentine <br />Newark, CA 94560 Davis, CA 95616 Fresno, CA 93722 <br />CAD980887418 CAD982446874 CAD982446882 <br />❑Evergreen Env. Svc.,ElEstxgl�tlaUnc.-SantaMaa❑ <br />16604 S. San Pedr 745 A West Betteravia <br />Carson, CA 907 Santa Maria, CA 93454 <br />CAD9816964 CAD982446858 <br />Source: LZCollection Station ❑ Government <br />❑ Marine ❑ Agricultural ❑ Industrial <br />DRIVER CHECKOL191,..� <br />Time Ir Time Out <br />O Tank/Drum Properly Labeled <br />❑ Accumulation Start Date Marked <br />❑ House Keeping - Tank/Drum Clean <br />❑ Other Services Checked: ❑ Oil, O FilterstDrums, ❑ Antifreeze <br />❑ Called in other services needed n Oil- n Filters/Dmms n Anti <br />Generator certifies that it has established a program to reduce the volume or <br />quantity & toxicity of the hazardous waste to the degree determined by <br />generator to be economically practicable. <br />I hereby certify that I have read and have the authority to <br />bind the above listed venerator to the terms on the reverse <br />side of this form <br />iia <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 />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 />,Dose include more stringent leak detection and prevention requirements, engineering certifications of tank integrity, and financial assurances for <br />ure 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 />not these more stringent Lequirements. This notification is for information purposes only. <br />Name Route # <br />o '�, <br />i'ienerator's Signature Print Name N11Date <br />White Copv=Customer Coov - Pink & Yellow Coov=Office Use - Green Conv=Attach to manifest - Gnldwn Grin=nrivar Cnnv <br />