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,wWW <br /> WORK OR SERVICE AGREEMENT <br /> . / Evergreen Environmental Services No 136302 <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 Dept. 2457 <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 Los Angeles, CA 90084-2457 Date: <br /> GENERATOR/JOB LOCATION BILLING INFORMATION <br /> N ME NAME CASH❑CHE <br /> ADDRESS ADDRESS CU TO�Cp�E NO. <br /> C STATE ZIP CO. CITY STATE ZIP CO. O# <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 Z .� <br /> Gal. <br /> Waste,Liquid Industrial CA221 Gal. <br /> Used Automotive Anti mem Non-RCRA Hazardous CA 134 Gal. <br /> Waste Liquid <br /> RQ Waste Combustible Liyuid,N.O.S.NA CA'21 Gal. <br /> 1993 ttt Oil contaminated with halo ens FOO VFlx12 <br /> Oil&Water,Non-RCRA Hazardous Waste Liquid CA221 Gal. <br /> Waste Solids and Sludges Gal. <br /> Each <br /> Wash Out <br /> Drained Used Oil Filters Drum <br /> Non-RCRA Hazardous Waste Solids(oily debris) CA223 Drum <br /> Drum <br /> Empty Drums <br /> Transportation Hrs. <br /> Non Hazar us Water Gal. <br /> TEST: Clor D Tech 4000 ppm ❑Clor D Tech 1000Vass Fail ❑ Halogen Detector/Flame Test ❑Pass Fail <br /> Total Char es <br /> Field Service Work Description: <br /> Other: <br /> iOther: <br /> qVas�e ' es Time <br /> On Site Off Site Off Loud Start Off Load End Return to Yard `0 <br />—� Consolidated Manifest <br /> green Oil,Inc. ❑ Evergreen Env.Svc. ❑ 413Eve9 NeValentin Env.nec � A5131JS tlter <br /> Clark Ave. El <br /> 0 Smith Ave. Road 30B <br /> Newark,CA 94560 Davis,CA 95926 Fresno,CA 93711 Industry,CA 91745 <br /> CAD980887418 CAD982446874 CAD982446882 CADOOM97432 <br /> ❑ Evergreen Env.Svc. ❑ Evergreen Env.Svc. ❑ CFR ❑ CFR Greenleaf Env.Svc. <br /> j ❑ 3474 To on Circle <br /> 16604 S.San P 'to 745 A West Betteravia 944 E.Blouson Ave. 33210 Western Toy <br /> on <br /> CA 9 46 Santa Maria,CA 93454 Los Angeles,CA 90011 Union City,CA 94587 Valley Springs,CA 95352 <br /> CAD98169( 0 CAD982446858 CAI-0001 10021 CALOW091507 CAL(X)0214411 <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 /> i, Ret sample # G <br /> side of this form. <br /> t ! , <br /> Dri r Signature Print Name Route# ate enerator's Signature Print Name Date <br /> 4,Oitil C T n/Lo <br />