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C_J <br /> WORK ORDER/SERVICE AGREEMENT <br /> Evergreen Environmental Services NO- 192358 <br /> dedicated to the protection of the envirrnunenl <br /> To schedule a pickup, call Send payment to: <br /> Sales Order# <br /> 800-972-5284 Evergreen Oil, Inc. <br /> 6880 Smith Ave.,Newark,CA EPAM CAD982413262 <br /> P.O. BOX 678252 pate: S 7 d <br /> Dallas,TX 75267-8252 <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 BILLING INFORMATIONGENERATORIJOB LOCATION NAME CASH C CK <br /> NAS # <br /> CU TO ER CODE NO. <br /> ADDRESS <br /> ADDRESS ✓, <br /> STATE %I I CO. CITY STATE 7IP CO. PO# <br /> CI Y �0 <br /> �,�( PROFILE NO. CUSTOMER EPA ID NO. <br /> PHONE NO. 9 <br /> PHONE NO. <br /> WASTE MANIFESTAMOUNT <br /> CODE NUMBER QUANTITY UNITS PRICE <br /> PRODUCT r .�O <br /> Gal. <br /> Used oil,Non-RCRA Hazardous Lubricating CA221 Gal <br /> Waste,Liquid <br /> Industrial CA221 Gal <br /> Used,-.-1011 Antifreett,Non-RCRA Hazardous CA 134 <br /> Waste Li uid CA221 Gal. <br /> RQ Waste Combustible Liquid.N.O.S.NA FU01tFW2 <br /> 1993 111 oil contaminated with halo•ens Gal. <br /> Oil&Water,Non-RCRA Hazardous Waste Liquid CA221 Gal. <br /> Waste Solids and Sludges Each <br /> Wash Out Drum <br /> Drained Used Oil Filters Drum <br /> Non-RCRA Hazardous W Ste Solids(oily debris) CA223 Drum <br /> Empty Drums Hrs. <br /> Transportation Gal. <br /> Non Hazar s Water <br /> TEST: Clor D Tech 4�PPm ❑Clor D Tech 1000 Pass❑Fail ❑ Halogen Dctector/Flame Test El Pass ❑Fall Total Ch es <br /> Field Service Work Description: <br /> Other: <br /> Other: 1 O <br /> Vacuum Se -es TimeOff Load End Return <br /> to Yard ` <br /> On Site Off Site Off Load Start <br /> Out of Y a Consolidated Manifest <br /> TS Evergreen Oil,Inc. Evergreen Env.Svc. ❑Evergreen Env.Svc. ❑ 1513-1 Clark Ave. ❑ <br /> ❑ Road 30B 4139 N.Valentine <br /> 6880 Smith Ave. Fresno,CA 93711 Industry.CA 91745 <br /> Newark,CA 94560 Davis, 24 95926 CAD982446882 CAD001)U97432 <br /> CApg80R87418 CAD982446874 Greenleaf Env.Svc. <br /> Evergreen Env.Svc. ❑ Evergreen Env.Svc. ❑CFR <br /> ❑ CFR ❑ 3474 Toyon Circle <br /> ❑ 16604 S.San P Sv 745 A West Betteravia 944 E�S lauson Ave. 33210 Western CAL000214411 <br /> Carson,CA 907 Santa Maria,CA 93454 As g1�es,CA 901111 21 Union <br /> AI n�C�X15�94587 Valley Spnngs1 CA 95352 <br /> CAD9816964 CAD982446858 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 /> Source: Collection Station ❑Government enerat generator to be economically practicable. <br /> ❑Marine ❑ Agricultural ❑ Industrial I hereb certify that I have read and have the authority to <br /> bind the above listed generator to the terms on the reverse <br /> G side of this form. <br /> i <br /> Ret I sample # � <br /> � Vactc <br /> D Signature Print Name Route # <br /> enerator's Signature Print Name Date <br />