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WORK ORDER/SERVICE AGREEMENT <br /> Evergreen Environmental Services No 280889 <br /> dedicated to the protection of the environment <br /> To schedule a pickup, call Send payment to: Sales Order# <br /> 800-972-5284 Evergreen Oil, Inc. <br /> 6880 Smith Ave., Newark,CA EPA#CAD982413262 P.O. BOX 678252 <br /> 16540 S. San Pedro St.,Carson, CA EPA#CAD982413262 Dallas,TX 75267-8252 Date: <br /> GENERATOR/JOB LOCATION BILLING INFORMATION <br /> NAME NAME CASH❑ CHECK❑ <br /> ADDRESS ADDRESS CUSTOMER CODE NO. <br /> CITY STATE ZIP CO. CITY STATE ZIP CO. PO# <br /> PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> Used oil.Non-RCRA Hazardous Lubricating CA221 Gal. <br /> Waste,Liquid Industrial CA221 Gal. <br /> Used Automotive ANifrce ,Non-RCRA H,,­do., <br /> duus CA 134 G211. <br /> Waste Li uid <br /> RQ Waate Combustible Liquid,N.11 NA CA"_l <br /> I""❑I oil contaminated with halo ens) F(NII/FIN)2 Gal. <br /> Oil &Water,Non-RCRA Hazardous Waste Liquid CA221 Gal. <br /> Waste Solids and Sludges Gal. <br /> Wash Out Each <br /> Drained Used Oil Filters Drum <br /> Non-RCRA Hazardous Waste Solids(oily debris) CA223 Drum <br /> Empty Drums Drum <br /> Transportation Hrs. <br /> Non Hazardous Water Gal. <br /> Glycol Bulk 50150 Gal. <br /> Glycol Bulk Cone. Gal. <br /> TEST:❑ Clor D Tech 40(10 ppm ❑Clor D Tech 1000❑Pass❑Fail ❑ Halogen Detector/Flame Test ❑Pass ❑ Fail <br /> Field Service Work Description: Total Charges <br /> Other: <br /> Other: <br /> Vacuum Services Time <br /> Out of Yard On Site Off Site Off Load Start Off Load End Return to Yard <br /> TSDF ❑ Consolidated Manifest <br /> ❑ Evergreen Oil, Inc. ❑ Evergreen Env.Svc ❑ Evergreen Env. Svc. ❑ AJS Filter ❑ <br /> 6880 Smith Ave. Road 30B 4139N.Valentine 15131 Clark Ave. <br /> Newark,CA 94560 Davis.CA 95616 Fresno,CA 93722 Industry.CA 91745 <br /> CAD980887418 CAD982446874 CAD982446882 CAD000097432 <br /> ❑ Evergreen Env.Svc. ❑ Evergreen Env.Svc. ❑ CFRElCFR ❑ Greenleaf Env.Svc. <br /> 16604 S. San Pedro 745 A West Betteravia 944 E.Slauson Ave. 33210 Western 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 CAD982446858 CAL000110021 CAL000091507 CAL000214411 <br /> Generator certifies that it has established a program to reduce the volume or <br /> Source: ❑ Collection Station ❑Government quantity&toxicity of the hazardous waste to the degree determined by <br /> ❑ Marine ❑ 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 sample # side of this form. <br /> Driver Signature Print Name Route # Date Generator's Signature Print Name Date <br />