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'PipWORK ORDER/SERVICE AGREEMENT <br /> Evergreen Envii nental Services N° 6237114 <br /> dedicated to the protection of the environment <br /> To schedule a pickup, call Send payment to: Sales Order# Cl�� '7 <br /> 800-972-5284 Evergreen Oil,Inc. <br /> 6880 Smith Ave.,Newark,CA EPA#CAD982413262 Dept.LA 23234 �J <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 Pasadena,CA 91185-3234 Date: —7—zz,- <br /> GENERATOR/JOB LOCATION BILLING INFORMATION <br /> NArPE I NAME CASH 0 CHECK <br /> ti C— # <br /> ADDRESS ADDRESS CUSTOMER CODE NO. <br /> KZz.) <br /> CITY STA E ZIP CITY STATE ZIP CO. PO# <br /> PfrONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. <br /> jn <br /> —�J�t"� ( ) f t; <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> Used oil,Non-RCRA Hazardous Lubricating CA221 7 © Gal. <br /> Waste,Liquid Industrial CA221 Gal. <br /> Used Automotive Antifreeze,Non-RCRA Hazardous CA 134 Gal. <br /> Waste Liquid <br /> RQ Waste Combustible Liquid,N.O.S.NA CA22I Gal. <br /> 1993 In Oil comamin ued with halogens) F001/F002 <br /> Oil&Water,Non-RCRA Hazardous Waste Liquid CA223 Gal. <br /> Non Hazardous Water Gal. <br /> Waste Solids and Sludges Gal. <br /> Wash Out Each <br /> Pressure Washer/Steam Cleaner Day <br /> Transportation Hrs. <br /> Fuel Surcharge % <br /> Glycol Bulk 50/ /Specify Product Gal. <br /> Glycol Bulnc./Specify Product <br /> Gal. <br /> TEST: Clor D Tech 400O (:Qppm Clor D Tech 1000 Pass ❑Fail <br /> Retain sample# Total Char es <br /> Required <br /> Field Service Work Description: <br /> Other: <br /> Other: <br /> TSD Consolidated Manifest D ER CHECKLIST <br /> XEvergree. <br /> Oil,Inc. ❑ Evergreen Oil,Inc.-Davis❑ Evergreen Oil,Inc.-Fresno ❑ Time In Time <br /> h Ave. Road 30B 4139 N.Valentine <br /> 12 A 94560 Davis,CA 95616 Fresno,CA 93722 ❑ Tank/Drum Properly Labeled <br /> 87418 AD982446874 CAD982446882 ❑ Accumulation Start Date Marked <br /> Env.Svc. Ev 0il Inc-SantaMaria❑ El House Keeping-Tank/Drum Clean <br /> .San Pedro 745 A West Betteravia ❑ Other Services Checked: ❑ Oil, ❑ Filters/Drums, ❑Antifreeze <br /> Carson,CA 907AOI Santa Maria,CA 93454 <br /> CAD9816964 CAD982446858 I❑ Called in other services needed ❑Oil, ❑ Filters/Drums, ❑Antifreeze <br /> Source: Collection Station Q Government 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 /> ❑ 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 /> side of 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 t at is not required to <br /> comply wi the more stringent requirements applicable to hazardous waste management facilities.California faciliti s that handle or process used <br /> oil are re red to meet those more stringent requirements,and some out-of-state facilities that process used oil also et those requirements. <br /> These in de more stringent leak tection and prevention requirements,engineering certifications of tank integrit a d financial assurances for <br /> closure d accidental releases.I is lawful to send used oil to out <br /> facilities that comply only with federal u oil management standards <br /> and no ese more stringent re irernents.This notification is for information purposes on y. <br /> ,17 <br /> Cly-0 -& z- 4;,11W <br /> ver Signature "'Print Name Route# Date Ge tor's Signatu P t Name Date <br /> tnrtio. r _r �� r'.,.,,, . oi..i, 9 V-11—, <br />