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WORK ORDER/SERVICE AGREEMENT <br /> Evergreen Environmental Services N° 85333 <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 �p Q <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 Los Angeles,CA 90084-2457 Date• lJ J <br /> GENERATORMOB LOCATION BILLING INFORMATION <br /> NA NAME CASH❑CHECK❑ <br /> ADDYSL.� ADDRESS CUT MER CODE NO. <br /> CI Y S� STATE ZIP CO. CITY STATE ZIP CO. <br /> PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. <br /> PRODUCT WASTE MANIFEST <br /> CODE NUMBER QUANTITY UNITS PRICE AMOUNT <br /> Used oil,Non-RCRA Hazardous Lubricating CA 221 &WOUY75 Gal. <br /> Waste,Liquid Industrial CA221 Gal. <br /> Ue Amandive Anlif.,Nm-RCRA WnNa¢ <br /> Wane V 'd CA134 Gel. <br /> RQW,* Cpnbuvtible tiquiQ NOS.NA CA221 <br /> 199a III Qlwndminead with W FOaIN002 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 /> Transponalion I-Im <br /> Non Hazardous Water G <br /> TEST: Clor D Tech 4000 ppm ❑Clor D Tech 1000 YPass❑Fail ❑Halogen Detectorrl a Test ❑Pass ❑Fail <br /> Field Service Work Description: Total Charges <br /> Other .._ <br /> Other: <br /> Vacuum Services Time .yyy <br /> Out of Yard On Site Off Site Off Load Stan Off Load End Re to Yard <br /> TSDF Consolidated Manifest <br /> K6880 Smith Ave. Road 30B 4193 N.Valentine 15131 Clark Ave.. <br /> veruecn Oil,Inc. ❑ Evergreen Env.Svc.. ❑ Evergreen Env.Svc. ❑ AJS Filter L1 <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 LlCFR. ❑ Greenleaf Env.Svc. <br /> 16604 S.San Pedro 745 A West Betteravia 944 E.Slalson 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 /> Source: Collection Station El 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 1 have read and have the authority to <br /> Rtn <br /> sample N. C i bind7t <br /> alove is eneratorto the terms on the reverse <br /> 3�aL <br /> Dri r <br /> Sienature Print Name Route# Date 4enels tetra ure Print Name Date <br />