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e WORK ORDER/S>ERVICE AGREEMENT E Vca �. ear �i �Fg tient' ltl Services 622874 dedicated to the prote n nj the environment To schedule a pickup, call Send payment to: Sales Order # 800-596-9455 Evergreen Oil, Inc. 6880 Smith Ave., Newark. CA EPA# CAD982413262 Dept. LA 23234 16540 S. San Pedro St., Carson, CA EPA# CAD982413262 Pasadena, CA 91185-3234 Date: I GENERATOR/JOB LOCATION BILLING INFORMATION NADIFk C_r_T ! NAME CASH CHECK UNITS PRICE AMOUNT QDD4RES 1 � r� CITYY ADDRESS C STO1V�� CODE 110 �'` `� f 6 STATE ZIP CO. CITY STATE ZIP CO. PO # Waste, Liquid Industrial CA22150703 ®? J�� Gal. PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. 14r-0 LA7� J-- C-4-2-11'fl 1 ( ) - C.dCI.D� 11 055 PRODUCT WASTE CODE MANIFEST QUANTITY NUMBER UNITS PRICE AMOUNT Used oil, Non-RCRA Hazardous Lubricating CA2a7k,6; fi� Gal. Waste, Liquid Industrial CA22150703 ®? J�� Gal. Used Automotive Antifreeze. Non-RCRA Hazardous Waste Liquid CA1 pV }—r4.J S Gal. RQ Waste Combustible Liquid, N.O.S. NA 1993 n1 (Oil conmmmmed with holo ensl CA221 Pool/Foo2 - �-y-� y - l fo .' aJ� , Gal. Oil & Water, Non-RCRA Hazardous Waste Liquid CA223 Gal. Non Hazardous Water Gal. Waste Solids and Sludges Gal. Wash Out Each Pressure Washer/Steam Cleaner Day Transportation Hrs. Fuel Surcharge % Glycol-Bulk5 50/Specify Product Gal. Glycol Bu-Conc./Specify Product Gal. TEST: Clor D Tech 4000 ppm Clor D Tech 1000 f Pass ❑ Fail Retain sample # Required 13 <Z1 40">`z _Ir Total Charges ' Field Service Work Description: Other: Other: TS Z Consolidated Manifest Evergreen Oil, Inc. Evergreen Oil, Inc. - Davis Evergreen Oil, Inc. - Fresno 6880 Smith Ave. ❑ Road 30B 4139 N. Valentine Newark, CA 94560 Davis, CA 95616 Fresno, CA 93722 CAD980897419 CAD982446874 CAD982446882 ❑Evergreen Env. Sv . ❑ Eve>gteen0il Lia.-SantaMazia❑ 16604S San Pe o 745 A West Betteravia Carson, CA 9 46 Santa Maria, CA 93454 CAD98169 0 CAD982446858 F urce: Collection Station ❑ Government ❑ Marine ❑ Agricultural ❑ Industrial 1) t `/ .j Time In Time Out Tank/Drum Properly Labeled Accumulation Start Date Marked House Keeping - Tank/Drum Clean Other Services Checked: ❑ Oil, ❑ Filters/Drums, ❑ Antifreeze ❑ Called in other services needed ❑ Oil, ❑ Filters/Drums, ❑ Antifreeze Generator certifies that it has established a program to reduce the volume or quantity & toxicity of the hazardous waste to the degree determined by generator to be economically practicable. I hereby certify that I have read and have the authority to bind the above listed venerator 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. T4'ege include more -stringent leak detection and prevention requirements. engineering certifications of tank integrity, and financial assurances for c)'osyre and accidental releases. It is lawful to send used oil to out-of-state facilities that c6rr}-ply only with federal used oil management standards aiid not these more stringent r6ouirements. This notification is for information purposes on Diver Si -nature -Pent Name Route # Date Generator's Signature Print Name Date t