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WORK ORD /SERVICE AGREEMENT <br /> Evergreen Environmental Services N° 168761 <br /> . dedicated to the protection of the environment <br /> To schedule a pickup, call Send payment to: Sales Order O <br /> 800-972-5284 Evergreen Oil, Inc. <br /> 6880 Smith Ave.,Newark,CA EPA#CAD982413262 P.O. BOX 678252 1-2- <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 Dallas,TX 75267-8252 Datc: (/ <br /> GE OR/JOB LOCATION BILLING INFOR ION <br /> 'JAR <br /> 4-F <br /> NAM X�p <br /> NAME CASH ❑ CHECK❑ <br /> _ # <br /> � <br /> A ADDRESS C O E CODE NO. <br /> CIT / S' A�F, C( . CITY STATE ZIP CO. O# <br /> P E /.� PHONE NO. PROFILE NO. STOME EPA ID NO <br /> I( 1J ( ) 52- <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 Antifteerx,Non-RCRA Hazardous CA 134 Gal. <br /> Waste Liquid <br /> RQ Waste Combustible Liquid.N.O.S.NA CA221 Gal. <br /> 1993 111(Oil contaminated with halo ens FII.ItFlx12 <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 Hazard. , aste Solids 'ly debris) CA223 Drum <br /> Empty Drums Drum <br /> Transportation Hrs. <br /> Non Hazardous Water Gal. <br /> TEST:❑Clor D Tech 4000 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 F1 Consolidated Manifest <br /> ❑ Evergreen Oil,Inc. ❑ Evergreen Env.Svc. ❑ Evergreen Env.Svc. ❑ AJS Filter ❑ <br /> 6880 Smith Ave. Road 30B 4139 N.Valentine 15131 Clark Ave. <br /> Newark,CA 94560 Davis,CA 95926 Fresno,CA 93711 Industry.CA 91745 <br /> CAD980887418 CAD982446874 CAD982446882 CAD000097432 <br /> ❑ Evergreen Env.Svc. ❑ Evergreen Env.Svc. ❑ CFR 1:1CFR ElGreenleafEnv,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 /> Fs <br /> ource: ❑Collection Station ❑Government quantity&toxicity of the hazardous waste to the degree determined by <br /> ❑Marine ❑ Agricultural ❑ Industrial generator to he 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 sa le # side of this form. <br /> Driv Signat c Print N iic Route # Date Generator's Signature Pr t Name Date <br />