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WORK ORDE ERVICE AGREEMENT Evergreen v1 Services O dedicated to the protection of the environment To schedule a pickup, call Send payment to:Sales Carder # 1(62. ®596-9455 Evergreen Oil, Inc. 6880 Smith Ave., Newark, CA EPA# CAD982413262 P.O. BOX 30517 ®� 16540 S. San Pedro St., Carson, CA EPA# CAD982413262 Los Angeles, CA 90030-0517 Date: GENERATOR/JOB LOCATION BILLING INFORMATION PRODUCT WASTE MANIFEST QUANTITY COBE NUMBER UNI'T'S PRICE AMOUNT CASH n E : E CA Gal. Waste, Liquid Industrial CA221 ... ADDRESS CA 134 CuSfONIERCODE RQwaste CambusEible Liquid, N.O.S. NA 1493 In Oil contaminated with halogens) CA22 t F001/F002 Gal. - - 'CIT STATE ZIP Co. �ITY STAT ZIP Co. Waste Solids and Sludges C..�� Gal Wash Out ONE NO.PROFILE r Drained Used Oil Filters NO. CUSTOMER iia. ID NO.' � rr J' CA223 Drum Empty Drums • 'a r PRODUCT WASTE MANIFEST QUANTITY COBE NUMBER UNI'T'S PRICE AMOUNT Used oil, Non-RCRA Hazardous Lubricating CA Gal. Waste, Liquid Industrial CA221 Gal. Used Automaiae Antifreeze. Non-RCRA Hazardous wase t.. n d CA 134 Gal. RQwaste CambusEible Liquid, N.O.S. NA 1493 In Oil contaminated with halogens) CA22 t F001/F002 Gal. - - Oil & Water, Non-RCRA Hazardous Waste Liquid CA22j D?g Gal. j a Waste Solids and Sludges Gal Wash Out Each Drained Used Oil Filters Drum Non-RCRA Hazardous Waste Solids (oily debris) CA223 Drum Empty Drums Drum Transportation Hrs. Non Hazardous Water Gal. Glycol Bulk 50%50 Gal Glycol Bulk Cone. Gal TEST`. ❑ Clor D Tech 4000 ppm ❑ Clor D Tech 1000 ❑ Pass ❑ Fail ❑ Halogen Detector/Flame Test ❑ P ❑ Faii Field Service Work Description: Total Cliariges Other: Other: Vacuum rvices Time Out of rd On Site Off Site Off Load Start Off Load End Retu to Yard 1 S ❑ Consolidated li�ialrecl I�Iazliei Evergreen Oil, Inc. F7 Evergreen Env. Svc. ❑ Evergreen Env. Svc. ❑ AJS Filter 6880 Smith Ave. L -j Road 30B 4139 N. Valentine 15131 Clark Ave. Newark, CA 94560 Davis, CA 95616 Fresno, CA 93722 Industry, CA 91745 CAD980887418 CAD982446874 CAD482446882 CAD000097432 ❑ Evergreen Env. Svc.[_ -]Evergreen Env. Svc . ❑ CFR CFR 16604 S. San Pedro ' 745 A West Betteravia 944 E. Slauson Ave. 33210 Western tJ 3474 Toyon Circle Carson, CA 90746 Santa Maria, CA 934 Los Angeles, CA 90011 Union City, CA 94587 Valley Springs, CA 95352 CAD981 6�966420 CAD982446858 CAL000110021 CAL000091507 CAL000214411 OtkrCe: rCollection Stationi30Verr1ffieItt Generator certifies that it has established a program to reduce the volume or quantity & toxicity of the hazardous waste to the degree determined by ❑ Marine Lj Agricultural Industrial generator to be economically practicable. I hereby certify that I have read and have the authority to bind the above listed generator to the terms on the reverse Retain sample side of this form. IMPORTANT NOTICE REGARDING G 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. These include more stringent leak detection and prevention requirements, engineering certifications of tank integrity, and financial assurances for Ac os re and accidental releases. It is lawful to send used oil to out-of-state facilities that comply only with federal used oil management standards nd of these more stringent requirements. This notification is for information purposes only. -lie ver Signature rint Name Route # Date enerator's Signat e Print Name Date