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fr <br /> WORK ORDER/SERVICE AGREEMENT ' <br /> Evergreen Environmental Services o N 7 <br /> dedicated to the m <br /> protection of the environment NO- 2 5 5 • 6 8 <br /> To schedule a pickup, call Send payment to: Safes Order ` r <br /> 800-972-5284 Evergreen Oil, Inc. <br /> 6860 Smith Ave.; Newark,CA EPA#CAD982413262 P.O. BOX 678252 <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 Dallas,TX 75267-8252 Datee"" <br /> GENERATOR/JOB LOCATION BILLING INFORMATION <br /> NA'I E4' ` J NAME , ;:-..- CASH❑ CHECK❑ <br /> ✓ >• t _ # <br /> ADDRESS, ., a'r _ �- fP ADDRESS "IrCUSTOMER �OIy1B NO...� <br /> CITY STATE Z ,,tEo CITYST ZIPCoi P # ' <br /> PHONE NO, PHONE NO. •fT PROFILE NO. _ N <br /> .? CUSTO ?�NO. <br /> PRODUCT WASTE MANIFEST <br /> CODE NUMBER QUA;;;Y7 UMTS PRICE AMOUNT <br /> Used oil,Non-RCRA Hazardous Lubricating CA221 Gal. <br /> Waste,Liquid Industrial CA221 Gal. <br /> w oe u aaUlr AN m.Na RCRA tv CA134 Gal. <br /> RQ Wmle Cmvbueable Liqui0.N o.a.NA CA221 <br /> r a m mi r�i�,�nms,.m mao Foot/ 2 Gal. <br /> . tten',j.4dr�RCRA,7fezard9u Waste 'd <br /> /C 24 Gal. <br /> Waste Solids end S)yfl .q; . r.. ?:.: ; <br /> Wash Out ti'' '' `'Y ' !,..=4^ Each <br /> Drained Used Oil Filters Drum <br /> Non-RCRA Hazardous Waste Solids(oily debris) CA223 <br /> Dram <br /> Empty Dmms .f Drum s-1 <br /> TranspormdonHm <br /> , <br /> Non Hazardous Water ' Gal. <br /> TEST:❑ Clot D Tech 4000_ppm ❑Our D Tech 1000❑Pass ❑Fail ❑ Halogen DetectorTlame Test ❑Pass ❑Fail _`f <br /> Field Service Work Description: - TOW Charges <br /> Other: <br /> Other: . J. f <br /> Vacuum Services Time '-•-+"` <br /> Out of Yard On Site Off Site Off Load Stan Off Load End Rehun to Yard <br /> TSDF I El Consolidated Manifest <br /> Evergreen Oil,e. ❑ Evergreen Env.Svc. Evergreen Env.Svc. ❑ AIS 1 Filter !,b. <br /> 6880 Smith Ave. Road 30B 4139 N.Valentine 15131 Clark Ave. <br /> Newark,CA 94560 Davis,CA 95926 Fresno,CA 93711 Industry,CA 917 <br /> CAD980887418 CAD982446874 CAD982446882 CAD000097432 <br /> Evergreen Env.Svc. I—I Evergreen Env.Svc. CPR ❑ CFR Gr{ettleaf`Env.Svcs <br /> 16604 S.Sao Pedro LJ 745 A West Beneravia 944 E. Slauson Ave. 33210 Western LLLJJJ 3474 Toyon Circle <br /> Carson,CA 90746 Santa Maria,CA 93454 Los Angeles,CA 90011 Union City,CA 94587 Valley Springs,CA 95352 <br /> CAD981696420 CAD992446858 CAL000110021 CAL000091507 CAL000214411 <br /> Source: ❑ Collection Station ❑Government Generator certifies that it has established a program to reducb&volume or <br /> quantity&toxicity of the hazardous waste to the degm�determined by <br /> D Marine D Agricultural ❑ Industrial 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 /> Retain sanlp}E side of this form. <br /> Driver S4gnature TAiint a Route# Date Generator's Signature ,Tint Name Date <br /> i <br />