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WORK ORDER/SERVICE AGREEMENT <br /> Evergreen Environmental Services 80240 <br /> dedicated to the protection of the environment <br /> To schedule a pickup,call Send payment to: Sales Order# <br /> 800-972-5284 Evergreen <br /> 6880 Smith Ave.,Newark, CA EPAI CAD982413262 P.O.Box 49065 <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 San Jose,CA 95161-9065 Date• <br /> GENERATORMJOB LOCATION BILLING INFORMATION <br /> NAME NAME CASH❑CHECK❑ <br /> # <br /> ADDRESS ADDRESS CUSTOMER CODE NO. <br /> CITY STATE zip. CO. CITY STATE ZIP CO. PO# <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 CA 221 _ Gal. <br /> Waste,Liquid Industrial CA221 Gal. <br /> Uved Amo rwt Ami..Non-RCRA Haurdoua CA 134 Gal. <br /> wum� and <br /> RQ Wavle Combuvible Wquid.N O.S.NA CA221 Gal. <br /> 1993111 OIcmWninetN wiN aN s F00i/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 r' Drum <br /> Non-RCRA Hazardous Waste Solids(oily debris) CA223 Drum <br /> Empty Drums-'.. - Drum <br /> Transportation Hrs. <br /> Non Hazardous Water Gal. <br /> TEST:❑Clor D Tech 4000_Ppm ❑ Clor D Tech 1000❑Pass❑Fail ❑ Halogen Detector/Flame Test ❑Pass ❑Fail <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 StartOff Load End Rehm to Yard <br /> TSDF H Consolidated Manifest <br /> ❑ Evergreen Oil,Inc. F-1 Evergreen Env.Svc.. Evergreen Env.Svc. ❑ AJS Filter <br /> 6880 Smith Ave. Road 30B 4193 N.Valentine 15131 Clark Ave.. LI <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 CFR. Greenleaf Env.Svc. <br /> 16604 S.San Pedro 745 A West Betteravia 11 944 E.Slauson Ave. 33210 Western 3474'royon 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 CALOOM1507 CAL0002MII <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 /> 1 hereby certify that 1 have read and have the authority to <br /> bind the above listed generator to the terms on the reverse <br /> Retain sample # side of this form. <br /> I <br /> Driver Signature Print Name Route 4 Date Generator's Signature Print Name Date <br />