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1010812010 10:09 <br />(FAQ P.0261045 <br />J WORK ORD&SERVICE AGREEMENT'�' <br />Evergreen Environmental Services p x <br />dedlcnted to the protection ofthe entrironrrtent — "�" ' ` <br />To schedule a pickup, call <br />800-596-9455 <br />Send payment to: Sales Order # <br />Evergreen 011, Inc. <br />6800 Smith Avc., Ne%v,", CA EPAA CAD982413262 <br />16540 S. San Pedro St.. Canion, CA EPA# CAD982413362 <br />Dept, LA 23234 I <br />Pasadena, CA 91185-3234 Date: 1 " <br />GENERATOR/JOB LOCATION <br />BILLING INIFORMATION <br />NAME <br />WASTE MANIFEST QUANTITY <br />CODE NUMBER <br />NAME <br />Used oil, Non-RCRA Hazardous Lubricating <br />CASH [:j CHECK <br />Waste, Liquid Industrial <br />CA221 <br />Gal. <br />U*idAuWurtMira rtmltnrxa. Mmi.RCRA HLW&US u <br />1 <br />ADDRESS <br />Gal. <br />ADDRESS <br />CAh <br />l±Q <br />CA223 <br />CUSTOMER CODE NO. <br />CITv <br />STATE ZIP . ^ CO. <br />CITY <br />STATE ZIP CO. <br />PO # <br />LHO]III NO. <br />Wash Out <br />PHONE NO. <br />Each <br />PROFILE ht0. <br />CUSTOMER EPA iD NO, <br />Day <br />Transportation <br />PRODUCT <br />WASTE MANIFEST QUANTITY <br />CODE NUMBER <br />UNITS PRICE AMOUNT <br />Used oil, Non-RCRA Hazardous Lubricating <br />CA221 <br />Waste, Liquid Industrial <br />CA221 <br />Gal. <br />U*idAuWurtMira rtmltnrxa. Mmi.RCRA HLW&US u <br />1 <br />CA 134'., tr { <br />Gal. <br />R1YaMeCambwdW.1quk1,N.Q.9.NA <br />.993 in (Oil md with n we <br />Oil & Water, Non-IRCRA Hazardous Waste Liquid <br />CAh <br />l±Q <br />CA223 <br />Gal. <br />Gal. <br />Non Hazardous Water <br />Gal, <br />Waste Solids and Sludges <br />Gal. <br />Wash Out <br />Each <br />Pressure Washer/Steam Cleaner <br />Day <br />Transportation <br />I-Irs. <br />Fuel Surcharge <br />% <br />Glycol Bulk 5Q/50/5pccify Product <br />Gal. <br />Glycol Bulk ConcJSpecify Product <br />Gal, <br />TEST: [❑ Clor D Tech 4000 ppm ❑ Clor D Tech i mo ® Pace ® Fail ® Pass ❑ Fail <br />Retain Sainple # <br />Re ui red <br />Field Service Work Description: <br />Other: <br />Other. <br />Total Charges <br />TSDF ❑ Consolidated Manifest DRIVER CHECKLIST <br />Ejevergreen 011, Inc. Eve eenesno" h7 Timc in_ ' 'lime out i <br />6880 Smith Ave, ❑ oil, Inc. • Davis Evergreen Oil, inc, - FrRoad 308 ❑ 4139 N. Valentine <br />Newark, CA 94560 Davis, CA 95616 Fresno, CA 93722 ❑ Tunk/Drum Properly Labeled <br />"CAD980887418 CAD982446874 CAD982446882 p Accumulation Start Date Marked <br />® Evergreen Env, Svc, ❑ BwL= 08,Inc.-SmmMs* ❑ !louse Keeping - Tank/Drum Clean <br />16604 S. San Pedro 745 A West Beuertavia ❑ Other Services CliccLcd: 0 Oil. ❑ Fihcrs/Drums, ® Amifrla:ze <br />Carson, CA 90746 Santa Maria CA 93454 <br />CAD981696420 CAD98244�i858 M Called in other servicch needed Lj Oil. 0 Filters/Drums. g Antifreeze <br />Source: [� Collection Station Government Generator cerillies that ii hus established a program to reduce the volume or <br />Q quantity & toxicity of the hazardous waste to die degree determined by <br />❑ Marine ❑ Agricultural ❑ Industrial generator to be economically practicable. <br />I hereby cera that I home read -and have the antliority tr <br />hind the above listed_Hcnemtor to the terms on the reverse <br />side gf this form. <br />IMPORTANT NOTICE REGARDING THE DISPOSITION OF YOUR OIL. <br />Per Californin Health and Safety Code Section 2$150.9, 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 faciiities that handle or process used <br />oil arc 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 Na1ne Route # Date Generator's'Signature Print Name Date <br />Wklo.. I"....,._P...,a...,.... A--, nl-1. a kI-n-... --_.. i.rrr.. r r .. .. ... . . .. - .. - - . - <br />