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264 #WORK <br />ORDAWSERVICE AGREEMENT <br />WASTE MANIFEST <br />CODE NUMBER <br />Evergreen Eni <br />ervics <br />Lubricating CA2 <br />Industrial CA221 <br />Gal. <br />dedicated to the protection of'the environment <br />N-0 580157 <br />Gal. <br />To schedule a pickup, call <br />Send payment to: <br />Sales Order # <br />Gal. <br />500-596-9455 <br />CA223 <br />Gal. <br />Non Hazardous Water <br />Evergreen Oil, Inc. <br />Gal. <br />6880 Smith Ave., Newark, CA EPA# CAD982413262 <br />16540 S. San Pedro St., Carson, CA EPA# CAD982413262 <br />Dept. LA 23234 <br />Pasadena, CA 91185-3234 <br />Date: <br />GENE <br />ATORfJOB LOCATION <br />BILLING INFORMATION <br />VM�i <br />fy <br />:r. J, - _ _ � <br />NAME <br />CASH f7 CHECK n <br />ZIP CO. I CITY <br />1 <br />PO # <br />NO. CUSTOMER EPA ID <br />i® <br />PRODUCT <br />WASTE MANIFEST <br />CODE NUMBER <br />QUANTITY UNITS PRICE AMOUNT <br />Used oil, Non-RCRA Hazardous <br />Waste, Liquid <br />Lubricating CA2 <br />Industrial CA221 <br />Gal. <br />Used Automotive Antifreeze, Non-RCRA Hazardous <br />Waste Liquid <br />CA 134 <br />Gal. <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993 III (Oil conte ninated with halo ens) <br />CA221 <br />MOURN <br />Gal. <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 4 <br />Hrs. <br />Fuel Surcharge <br />% <br />Glycol Bulk 50/5 Specify Product <br />Gal. <br />Glycol Bulk nc./Specify Product <br />Gal. <br />TEST: Clor D Tech 40 <br />ppm <br />Clor D Tech 1000 Pass Fail <br />Retain Sample <br />Required <br />Total Charges <br />Field Service Work Description: <br />Other: <br />Other: <br />TS Consolidated Manifest <br />Evergreen Oil, Inc. ❑ Evergreen oil, Inc. - Davis ❑ Evergreen Oil, Inc. - Fresno <br />6880 Smith Ave. Road 30B 4139 N. Valentine <br />Newark, CA 94560 Davis, CA 95616 Fresno, CA 93722 <br />CAD980887418 CAD982446874 CAD982446882 <br />❑Evergreen Env. Svc. ❑ EveU=Oil,lnc.-SantaMffiia <br />16604 S. San Pedr 745 A West Betteravia ❑ <br />Carson, CA 9074 Santa Maria, CA 93454 <br />CAD9816964290 CAD982446858 <br />Source:&!rnineil�j <br />ectStation ❑ Government <br />Agricultural ❑ Industrial <br />,:, ..t \ , <br />❑ Time In Time Out <br />❑ Tank/Drum Properly Labeled <br />❑ Accumulation Start Date Marked <br />❑ House Keeping - Tank/Drum Clean <br />❑ Other Services Checked: ❑ Oil, ❑ Fitters/Drums, ❑ Antifreeze <br />Called in other services needed n Oil <br />Antifreeze <br />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 />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 that is not required to <br />com with the more stringent requirements applicable to hazardous waste management facilities. California facilities that handle or process used <br />oil e equired to meet those more stringent requirements, and some out-of-state facilities that process used oil also meet those requirements. <br />Th se ' crude more stringent leak detection and prevention requirements, engineering certifications of tank integrity, and financial assurances for <br />cl ur 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 />an no these more stringe requirements. This notification is for information purposes only. <br />�P <br />D ver Signature Print Name Route # Date <br />