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WORK ORDER/SERVICE AGREEMENT
<br />Evergreen Envionmeh6 Services No $ 2 2
<br />dedicated to the protectionafthe en`vironmen ..:._E
<br />44 To schedule a pickup, call Send payment to:
<br />Sales Order
<br />800-596-9455 Evergreen Oil, Inc.
<br />6080 Smith Ave., Newark, CA EPA# CAD982413262 - P.O. BOX 30517
<br />16540 S. San Pedro St., Carson, CA EPA# CAD982413262 Los Angeles, CA 90030-0517 Date:
<br />GENERATOR/JOB LOCATION BILLING INFORMATION
<br />TSDF
<br />Evergreen Oil, Inc. Evergreen Env. Svc.
<br />6880 Smith Ave. Road 30B
<br />Newark, CA 94560 Davis, CA 95616
<br />CAD980887418 CAD982446874
<br />OlConsolidated Manifest
<br />❑Evergreen Env. Svc. AJS Filter.
<br />4139 N. Valentine 1:115131 Clark Ave.
<br />. Fresno, CA 93722 Industry, CA 91745
<br />CAD982446882 CAD000097432
<br />❑Evergreen Env. Svc. F-1 Evergreen Env. Svc. ❑ CFR El CFR El Greenleaf Env. Svc.
<br />16614 S. San Peden 745 A West Betteravia 944 E. Slauson Ave. 33210 Western 3474 rayon Circle
<br />Carson, CA 90746 Santa Maria, CA 93454 Los Angeles, CA 90011 Union City, CA 94587 Valley Springs, CA 95352
<br />CAD981696420 CAD982446858 CAL000110021 CAL000091507 CAL00021441I
<br />Generator certifies that it has established a program to reduce the volume or
<br />Source: ❑ Collection Station ❑ Government quantity & toxicity of the hazardous waste to the degree determined by
<br />❑ Marine ❑ Agricultural ❑ Industrial generator to be economically practicable.
<br />I hereby certify that I have read and have the authority to
<br />bind the above listed generator to the terms on the reverse
<br />Retain sample # side ol'this form.
<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 />These include more stringent leak detection and prevention requirements, engineering certifications of tank integrity, and financial assurances for
<br />closure 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 />and not these more stringent requirements. This notification is for information purposes only.
<br />Driver Signature Print Name Route # Date Generator's Sipriature. Print Name Date
<br />NAME
<br />-
<br />CASH ❑ CHECK ❑
<br />ADD S
<br />ADDRESS
<br />�C T.OME,Q D��NO.
<br />CIT STATE ZIP CO.
<br />CITY
<br />STATE ZIP CO.
<br />PO #
<br />PHONE N9
<br />PHONE NO.
<br />PROFILE NO.
<br />CUSTOMER EPA .ID_NO.
<br />PRODUCT
<br />WASTE
<br />CODE
<br />MANIFEST
<br />NUMBER
<br />QUANTITY UNITS PRICE
<br />AMOUNT
<br />Used oil, Non-RCRA Hazardous Lubricating. :CA221.
<br />Gal:-
<br />Waste, Liquid Industrial
<br />CA221
<br />`� Gal.
<br />U1 A,U,0 live Anlirreezq Non-RCRA HazaNws
<br />Wuid
<br />asm L,
<br />CA 134
<br />(_i -•al.
<br />RQ Wass Combustible Liquid. N.O.S. NA
<br />199J 111 (.acanmmina¢d wnM1 ,.,.,u)
<br />CA221
<br />m01/FD02
<br />Gal.
<br />I
<br />Oil & Water, Non-RCRA Hazardous Waste Liquid
<br />CA221
<br />Gal.
<br />Waste Solids and Sludges
<br />Gal.
<br />Wash Out
<br />Each
<br />Drained Used Oil Filters
<br />Drum
<br />Nan-RCRA Hazardous Waste Solids (oily debris)
<br />CA223
<br />Drum
<br />Empty Drams
<br />Drum
<br />Transportation
<br />Hrs.
<br />Non Hazardous Water
<br />Gal.
<br />Glycol Bulk 50150
<br />Gal.
<br />Glycol Bulk Cone.
<br />Gal.
<br />TEST: ❑ Clor D Tech 4000—ppm ❑ Clor D Tech 1000 ❑ Pass E]Fail E]Halogen Detector/Flame Test ❑ Pass ❑ Fail
<br />Field Service Work Description:
<br />Total ChaReS
<br />Other:
<br />Other:
<br />Vacuum Services Time
<br />Out of Yard - On Site Off Site
<br />Off Load Stan
<br />Off Load End Return to Yard
<br />TSDF
<br />Evergreen Oil, Inc. Evergreen Env. Svc.
<br />6880 Smith Ave. Road 30B
<br />Newark, CA 94560 Davis, CA 95616
<br />CAD980887418 CAD982446874
<br />OlConsolidated Manifest
<br />❑Evergreen Env. Svc. AJS Filter.
<br />4139 N. Valentine 1:115131 Clark Ave.
<br />. Fresno, CA 93722 Industry, CA 91745
<br />CAD982446882 CAD000097432
<br />❑Evergreen Env. Svc. F-1 Evergreen Env. Svc. ❑ CFR El CFR El Greenleaf Env. Svc.
<br />16614 S. San Peden 745 A West Betteravia 944 E. Slauson Ave. 33210 Western 3474 rayon Circle
<br />Carson, CA 90746 Santa Maria, CA 93454 Los Angeles, CA 90011 Union City, CA 94587 Valley Springs, CA 95352
<br />CAD981696420 CAD982446858 CAL000110021 CAL000091507 CAL00021441I
<br />Generator certifies that it has established a program to reduce the volume or
<br />Source: ❑ Collection Station ❑ Government quantity & toxicity of the hazardous waste to the degree determined by
<br />❑ Marine ❑ Agricultural ❑ Industrial generator to be economically practicable.
<br />I hereby certify that I have read and have the authority to
<br />bind the above listed generator to the terms on the reverse
<br />Retain sample # side ol'this form.
<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 />These include more stringent leak detection and prevention requirements, engineering certifications of tank integrity, and financial assurances for
<br />closure 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 />and not these more stringent requirements. This notification is for information purposes only.
<br />Driver Signature Print Name Route # Date Generator's Sipriature. Print Name Date
<br />
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