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WORK ORDER/SERVICE AGREEMENT <br />WA <br />dedicated to the protc, n of the environment <br />To schedule a pickup, call Send payment to: Sales Order # <br />800-596-9455 Evergreen Oil, Inc. <br />6880 Smith Ave., Newark, CA EPA# GAD982413262 Dept. LA 23234 <br />16540 S. San Pedro St., Carson, CA EPA# CAD982413262 Pasadena, CA 91185-3234 Date: 62 _Z71 ® 6 <br />GENERATOR/JOB LOCATION BILLING INFORMATION <br />N <br />NAME <br />CASH [:] CHECK <br /># <br />DD � ` <br />ADDRESS <br />CU STO ER C:)N0. <br />CITY ,.. STATE �Z^I_P CO. <br />CITY STATE ZIP CO. <br />PO # <br />PHINE NO. <br />PHONE NO. <br />PROFILE NO. <br />I CUSTOMER EPA ID NO. <br />PRODUCT <br />WASTE MANIFEST CODE NUMBER <br />QUANTITY UNITS PRICE <br />AMOUNT <br />Used oil, Non-RCRA Hazardous Lubricating <br />CA2Cr <br />Gal. <br />Waste, Liquid Industrial <br />CA221 <br />Gal. <br />Used Automotive Antifreeze. Non-RCRA Ho dour <br />Waste Li uid - <br />CA] 34 <br />Gal. <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993 ill (Oil contaminated with halo ens) <br />CA221 <br />F001/F002 <br />G. <br />Oil & Water, Non-RCRA Hazardous Waste Liquid <br />CA223 <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 j' <br />Hrs. <br />Fuel Surcharge <br />% <br />Glycol Bulk 50/ /Specify Product <br />Gal. <br />Glycol Bu onc./Specify Product <br />Gal. <br />TEST: FT Clor D Tech 400 ppm <br />F-1 Cl or D Tech 1000 Pass F� Fail <br />Retain Sample # ` <br />Required / t <br />Total Charges <br />Field Service Work Description: <br />Other: <br />Other: <br />_^ <br />TSDI( [X Consolidated Manifest DRIVER CIIEC <br />eEvergte_n Oil, Inc. Evergreen Oil, Inc. - Davis ❑ Evergreen Oil, Inc. - Fresno ❑ Time In Time Out <br />688- Smith Ave. Road 3013 4139 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 />❑Evergreen Env. Svc. Eva@1ee MIm.- Santa Maria F7 ❑ House Keeping - Tank/Drum Clean <br />16604 S. San Pec r 745 A West Betteravia ❑ Other Services Checked: ❑ Oil, ❑ Filters/Drums, ❑ Antifreeze <br />Carson, CA Santa Maria, CA 93454 <br />CAD981696907 CAD982446858 10 Called in other services needed ❑ Oil, E] Filters/Drums, ❑ Antifreeze <br />Source: Collection Station ❑ 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 herebycertify ertify 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 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 are 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 neat these more stringent requirements. This notification is for information purposes only. <br />r <br />Diver Signature Print Name Route # Date Generator's Signature Print Name Date <br />