COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

WORK ORDER/SERVICE AGREEMENT �j Evergreen Envirc nental Services NO- 384472 dedicated to the protection of the environment To schedule a pickup, call Send payment to: Sales Order # / , 7r 800-596-9455 Evergreen Oil, Inc. 6880 Smith Ave.,Newark,CA EPA#CAD982413262 P.O. BOX 30517 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 Los Angeles, CA 90030-0517 " Date: '' a GENERATOR/JOB LOCATION BILLING INFORMATION NAME NAME CASH❑CHECK❑ — s ADDRESS ADDRESSCUSTOMER CODE NO. CITY STATE ZIP CO. CITY ~STATE ZIP CO. PO# PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT CODE NUMBER Used oil,Non-RCRA Hazardous Lubricating CA221 Gal. Waste,Liquid Industrial CA221 Gal. Used Automotive Antifreeze,Non-RCRA Hazardous CA134 Gal. Waste Liquid RQ Waste Combustible Liquid,N.O.S.NA CA221 Gal. 1993 In Oil contaminated with halo ens F001/F002 Oil&Water,Non-RCRA Hazardous Waste Liquid CA221 Gal. Waste Solids and Sludges -']/61 Gal. Wash Out J Each Drained Used Oil Filters Drum Non-RCRA Hazardous Waste Solids(oily debris) CA223 Drum Empty Drums Drum Transportation y Hrs. Non Hazardous Water L r Gal. r'�l'ycol Bulk 50/50 Gal. Glycol Bulk Conc. Gal. TEST:❑ Clor D Tech 4000 ppm ❑Clor D Tech 1000❑Pass❑Fail ❑'Halogen Detector/Flame Test ❑Pass ❑Fail Field Service Work Description: Total Charges Other: Other: Vacuum Services Time Out of Yazd On Site Off Site Off Load Start Off Load End Return to Yard TSDF ❑ Consolidated Manifest vergreen Oil,Inc. ❑ Evergreen Env.Svc. El4139 Env.Svc. ❑ AJS Filter ❑ 6880 Smith Ave. Road 30B 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. ❑ Evergreen?}Env.Svc. ❑ CFR ❑ CFR ❑ Greenleaf Env.Svc. 16604 S.San Pedro 745 A W94t 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 Generator certifies that it has established a program to reduce the volume or Source:, Collection Station ❑Government 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 bind the above listed generator to the terms on the reverse Retain sample # 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 e required to meet those more stringent requirements, and some out-of-state facilities that process used oil also meet those requirements. fese 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