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WORK ORDER/SERVICE AGREEMENT <br /> Evergreen Environmental Services SOtg <br /> :,.,. <br /> dedicated to the protection of the environment '?*• :,. <br /> To schedule a pickup,call Send payment to: Sales Order lb <br /> 800-972-5284 Evergreen Oil,Inc. <br /> 6880 an 29 Ave.,Newark, CA EPA#F CADM413262 Dept.2457 x <br /> 16540 S.San Pe"SL,Carson,CA EPA#CAD8e2413262 Los Angeles,CA 90084-2457 <br /> GENERATORMJOB LOCATION BILLING INFORMATION <br /> NAr4E '-. _ mr. NAMEi' _ �: : •p .l ,y CASH❑CHECK❑ <br /> RESS - ADDRESS - . . . <br /> CUSTOMER CODE NO. <br /> CIyY , STATE ZIP CITx, - ATE ZIP CO. PO <br /> PHONE Rt - PROFILE NO. t n M R E ID NO. <br /> t ( > • <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> Used oil,Non-RCRA Hawdaa Lubricating CA 221 Gal. <br /> Waste,Liquid Industrial CA221- Gal. <br /> Uma Awm—Avtiaeeu,N CRA ta.ram,.. CA134 Gd. <br /> Ww�u a <br /> 9g911�0i1 canlawbvtd myi 01 NA rWe�a.W3 Gal. <br /> oil&Water,Nar-RCRA Hazardous Waste Liquid CA221 Gal. <br /> Waste Solids and Sludges Gal. <br /> Wash Out Each <br /> Drained Used Oil Filters Drum <br /> Nai-RCRA Hazardous Waste Solids(oily debris) CA273 Drum <br /> Empty Drums Drum <br /> Transportation Hrs. <br /> Non Hazardous Water Gal. <br /> TEST:❑Cbz D Tech 4000__ppm ❑Cldr D Tech 1000❑Pass❑Fail ❑Halogen Detectcx1Name Test ❑Pass [-]Fail <br /> J <br /> Field Service Work Description. �,S` '- ,_ `• ,j .�•`��. "# Total Charges <br /> r ✓ <br /> Vacuum Services Time <br /> Out of Yard On Site Off Site Off Load Stan Off Load End Return to Yard <br /> TSDF U Consolidated Manifest <br /> O6980 Evergreen Oil,Inc. RoadEvergreen0B Em.Svc.. ❑ Evergreen Env.Svc. 1AJS51 Filter El <br /> 6880 Smith Ave. Road 306 Fres o, Valentine Indus Clark Ave.. <br /> Newark,CA 94560 Davis, 24 95926 Fresno,CA 93711 Industry,CA 91745 <br /> CAD980887418 CAD982446874 CAD982446882 CAD000097432 <br /> ❑ Evergreen Env.Svc. F-1Evergreen Env.Svc. ❑ CFR ❑ CFR leaf Env.Svc. <br /> 16604 S.San Pedro 745 A West Beaeravie 944 E.Slauson 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 /> Source: Generator certifies that it has established a program to reduce the volume or <br /> El Collection Station 13 GoveInlrient <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 1 have read and have the authority to <br /> bind the above listed generator to the terms on the reverse <br /> Retain sample# side ofthis form.. <br /> Driver Sienature Print Name, Route# Date Generator's Signature Print Name Date <br />