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WORK ORlll,'.l ERVICE AGREEMENT <br /> Evergreen Environmental Services <br /> dedicated to the protection of the environment N_ 151254 <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: ( Zlo 6�3 <br /> GENERATOR/JOB LOCATION BILLING INFORMATION �— <br /> NA E NAME CASH C CK <br /> ADDRESS r # <br /> ADDRESS CU TOME C E NO. <br /> S� �uc) <br /> CI STATE ZIP CO. CITY STATE ZIP CO. PO# <br /> �' OS <br /> PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. <br /> cnsY �• <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> Used oil,Non-RCRA Hazardous Lubricating CA221 -7 ao Gal. <br /> Waste,Liquid Industrial CA221 Gal <br /> Used Automotive Antifrecm.Non-RCRA Hazardous <br /> Waste Li aid CA134 Gal. <br /> RQ Waste Combustible Liquid,N.O.S.NA CA221 <br /> 1993 111 Oil contaminated with halo ens FOOI IF002 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 /> Transportatio <br /> Hrs. <br /> Non Haz ous Water Gal. <br /> TESTI Clor D Tech 4000ZZp_ppm ❑Clor D Tech 1000 Pass❑Fail ❑ Halogen Detector lame Test ❑Pass ❑Fail <br /> Field Service Work Description: Total Charges <br /> Other: <br /> Other: <br /> Vacuum Se ces Time <br /> iOut of Y d On Site Off Site Off Load Start Off Load End Return to Yard <br /> TS 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.Sv . ❑ Evergreen Env.Svc. ❑ CFR ❑ CFR ❑ Greenleaf Env.Svc. <br /> 16604 S.San Pc o 745 A West Betteravia 944 E.Slauson Ave. 33210 Western 3474 Toyon Circle <br /> Carson,CA 9( 6 Santa Maria,CA 93454 Los Angeles,CA 90011 Union City,CA 94587 Valley Springs,CA 95352 <br /> CAD98I69 ..0 CAD982446858 CAL(XX) CALO(NX)91507 CAUX)0214411 <br /> Source: 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 /> R i sample # bind the above listed generator to the terms on the reverse <br /> C• _ side of-this form. <br /> 1� NJf <br /> '7, yy b 7 2 <br /> Dri Signature Print Name Route# Dale Generator's Signature Print Name Date <br /> tJA-D /0c_� 7-4 /Apoe.614- <br />