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WORK ORDERISERVICE AGREEMENT <br /> Evergreen Enviro ental Services No 113200 <br /> dedicated to lite prolcctiutt ul the environniew <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 Dept. 24.57 <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 Los Angeles, CA 90084-2457 Date: I <br /> GENERATOR/JOB LOCATION BILLING INFORMATION <br /> NAME NAME CASH F <br /> # `1 <br /> A RESS . ADDRESS CU.'TOMF,R CODE NO. <br /> I /WS77 —)C>. o Up I <br /> CITY STATE ZIP CO. CITY STATE ZIP CO. 110# <br /> 5–Lcl;r <br /> PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. <br /> &'1 ) 4- — 1 cxp ( ) <br /> PRODUCT WASTE MANIFEST CODE NUMBERQUANTITY UNITS PRICE AMOUNT <br /> Used oil,Non-RCRA Hazardous Lubricating CA221 c);A2o3 q50 Gal. L6 y <br /> i <br /> Waste,Liquid Industrial CA221 Gal. <br /> Used Automotive Antifreem.Non-RCRA Hazardous CA 134 Gal. <br /> Wmtc Liquid <br /> RQ Waste Combustible Liquid.N.O.S.NA CA221 Gal <br /> ..,.."o <br /> .,In Oil conuminated with halo ens Ftx)1/F002 <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 Dnim <br /> Non-RCRA Hazardous Waste Solids(oily debris) CA223 Drum <br /> Empty Drums Drum <br /> Transportation/,, Hrs. <br /> i <br /> Non Hazar us Water Gal, <br /> TEST: Clor D Tech 4000,&A;—Dppm ❑Clor D Tech IOOOX'Pass❑Fail ❑ Halogen Detector/Flame Test ❑Pass ❑Fail _JQ <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 4139 N.Valentine 15131 Clark Ave. <br /> Newark,CA 94560 Davis,CA 95926 Fresno,CA 93711 Industry,CA 91745 <br /> CAD980887418 CAD982446874 CAD982446882 CAD(H)0097432 <br /> ❑ Evergreen Env.Svc. ❑ Evergreen Env.Svc. ❑ CFR1:1CFR ❑ 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 9001 I Union City,CA 94587 Valley Springs,CA 95352 <br /> CAD981696420 CAD982446858 CAL000110021 CAL000091507 CAL.000214411 <br /> Source: Ll Collection Station ❑Government 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 /> ❑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 /> e ain sample # y G side of this form. <br /> Zo�� <br /> D -ver Signature Print Name Route# Date enerator's Signature . Print Name Date <br /> /- <br />