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WORK ORDER/SERVICE AGREEMENT • Evergreen Envi>ilpmental Services f t(e�cfued to the protection of the environmNent ' •O �ry`^' `^g/q 3 Y ;r1q 37 �o schedule a pickup, call Send payment to: Sales Order # 800=596-9455 Evergreen Oil, Inc. 6880 Smith Ave., Newark, CA EPA# CAD982413262 P.O. BOX 30217 16540 S. San Pedro St., Carson, CA EPA# CAD982413262 Los Angeles, CA 90030-0517 Date: GENERATOR/JOB LOCATION ntr r Twt, ytvieniaxxAmrn, , NAME ADDRESSADDRESS NAME _ .. uv �• Evergreen Oil, Inc.❑ 6880 Smith Ave. CASH CHECK EJ CUSTOMER CODE NO. CITY STATE ZIP CO. CITY STATE ZIP CO. PO # PHONE NO. ( ) 4139 N. Valentine PHONE NO. ) PROFILE NO. CUSTOMER EPA ID NO. Fresno, CA 93722 Industry, CA 91745 CAD980887418 CAD982446874 CAD982446882 PRODUCT HASTE CODE MANIFEST QUANTITY NUMBER UNITS PRICE�AMOUNT Used oil, Non-RCRA Hazardous Lubricating CA22P {at y Gal _ Waste, Liquid Industrial CA221 Gal. W.It Aummmive Amifrtcu. NnmRCRA Huzvaom warm L. ma CA 134 Gal. RQ Wane Combustible Liquid N.O.S. NA 1993111 foil comaminaw wtlh Nlo ens, CA221 haul 2 Gal. Oil & Water, Non-RCRA Hazardous Waste Liquid CA221 Gal. Waste Solids and Sludges Gal. Wash Out Each Drained Used Oil Filters Drum Non-RCRA Hazardous Waste Solids (oily debris) C 22 Drum Empty Drums Drum Transportation Hrs. Non Hazardous Water Gal. Glycol Bulk 50/50 Gal. Glycol Bulk Cone. Gal TEST: 0 Clor D Tech 4000_ppm Q Clor D Tech 1000 ❑ Pass ❑ Fail ❑ Halogen Detector/Flame Test El Pass Fail Field Service Work Description: TOtal Charges Other: Other: Vacuum Services Time _.. .... Out of Yard On Site Off SiteOf Load StartOff Load End Return to Yard TSDF ❑ Consolidated Manifest Evergreen Oil, Inc.❑ 6880 Smith Ave. Evergreen Env. Svc. Road 30B ❑ Evergreen Env. Svc. ❑ AJS Filter ❑ 4139 N. Valentine 15131 Clark Ave. Newark, CA 94560 Davis, CA 95616 Fresno, CA 93722 Industry, CA 91745 CAD980887418 CAD982446874 CAD982446882 CAD000097432 ❑ Evergreen Env. Svc.ElEvergreen Env. Svc. 11CFR 11CFR Greenleaf Env. Svc. 16604 S. San Pedro 745 A West Betteravia 944 E. Slauson Ave. 33210 Western ❑ 3474 Toyon Circle Carson, CA 90746 Santa Maria, CA 93454 Los Angeles, CA 90011 Union City, CA 94587 Valley Springs, CA 95352 CAD981696420 CAD982446858 CAL000110021 CAL000091507 CAL000214411 Source: ❑Collection Station ❑ Government quantity certifies that it has established a program to reduce the volume or quantity & toxicity of the hazardous waste to the degree determined by ❑ Marine ❑ Agricultural ❑ Industrial generator to be economically practicable. I hereby certify that I have read and have the authority to Retain sample # bind the above listed generator 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 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 and not these more stringent requirements. This notification is for information purposes only. Driver Signature Print Name Route # Date Generator's Signature Print Name Date