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WORK ORDEOSERVICE AGREEMENT <br /> .0 Evergreen Environmental Servicesc <br /> dedicated to the ptvrection of the environment N_ 5 5 4 7 4 7 <br /> 4To schedule a pickup,call Senda ment to: <br /> P Y Sales Order# <br /> 800-596-9455 Evergreen Oil,Inc, <br /> 6880 Stnith Ave„Newark,CA EPA#CAD982413262 Dept,LA 23234 <br /> 16540 S,San Pedro St.,Caraon,CA EPA#CAfD942413262 Pasadena,CA 91185-3234 Date;-,A2-11 <br /> GENERATOR/JOB LOCATION 13ILLING INFORMATION <br /> NAr NAME CASH F]CHECK❑ <br /> c� # <br /> D KESS ADDRESS CUSTOMER CODE NO, <br /> STA E .ZIP C-0 CITY STATE ZIP CO. PO# <br /> PHO ENO. PHONE NO, PROFILE NO. CUSTOMER EPA ID Nd <br /> .- <br /> 1( i 1-7 <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> Used oil,Non-RCRA Hazardous Lubricating CA2261Gal. <br /> Waste,Liquid lndustnal CA221 Gal, <br /> u;L!o 111 A.ifmw,Noe-RCRA H04dou CA l34 Gal. <br /> RQ]W,14 Lldgwld1oob,9wrA <br /> 1IidhG12Z <br /> Gal. jCT to, 6 - <br /> Oil&Water,Non-RCRA Hazardous Waste Liquid CA223 Gal. <br /> Non Hazardous Water Gal, NM <br /> Waste Solids and Sludges Gal lac t ru nc:o <br /> Wwh Out Each <br /> Pressure Washer/Steam Cleaner Day <br /> Transportation Hrs. <br /> Fuel Surcharge % <br /> Glycol Bulk 5960/Specify Product Gal. <br /> Glycol But onc,/Specify Product Gal. <br /> TES ` C1,D Tech 4000-L=ppm ❑Clor D Tech 1000❑Pam. Q Fail Pass ❑Fail <br /> Retain sample# Total Charges <br /> Required /D "-'- / i( <br /> Field Service Work Description: <br /> Other: <br /> Other: <br /> VE;8,0, <br /> Consolidated ManifestDRIV HECKL)<ST <br /> green Oil,Inc. EvetgTeettgI,Inc.-Davis❑ Evergreen Oil,ine.-Fresno O Time 1n 15me Out Smith Ave. Road 4134 N.Valentine <br /> Newark,CA 94560 Davis,CA 95616 Fresno,CA 93722 ❑ Tank/Drum Properly Labeled <br /> CAD980887418 CAD982446874 CAD982446882 ❑ Accumulation Start Date Marked <br /> ❑ Evergtv+:n Env.Svc. ❑ > pil,Inc.SmtmMuiul—I ❑ House Keeping-Tank/Drum Clean <br /> 16644 S.$an Pedro 74-5-A West Bencravia L J ❑ Other Services Chcckcd: ❑Oil, ❑ Filters/Drums, ❑Antifreeze <br /> Carson,CA 907 Santa Maria,CA 93454 <br /> CAD9816964 CAD982446858 ILI Called in other scrvicc8 needed Oil p Filters/Drums,Ei Antifreeze <br /> Generator certifies that it has established u program to reduce the volume or <br /> Source: Collection Station ❑GoveMment quantity&toxicity of the hazardous waste to the degree determined by <br /> ❑Marine Q Agricultural ❑ Industrial generator to be economically practicable. <br /> have road and bave the authodty W <br /> bind the above listed generator to the terms on tha rryp= <br /> side of this form, <br /> IMPORTANT NOTICE REGARDING THF~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 arc required to meet those more strin�cnt 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 /> closur3nd 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 t hese more stringent requirements.This notification is for information purposes only- <br /> Le-001 <br /> ver Signature Print Name Route# Date Generator's Signature Print Name Tate <br /> ZZO1L00A (k4 WK SLOZ19010L <br />