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WORK ORDER/SERVICE AGREEMENT <br /> e $0909vergreen Environmental Services g�Z <br /> dedicated to the protection of the environment )!J <br /> To schedule a pickup, call Scud paym"t t0: Sales Order 6 <br /> 800-972-5284 Evergreen � ) _ <br /> / 2 L <br /> 6660 Smith Ave.,Newark P.O.Bot 49065 Date, <br /> CA EPA#CAD962413262 San Jose,CA 95161-9065 <br /> 16540 S.San edm St.,Carson,CA EPA#CAD982413262 BILLING i MATION <br /> GENE R/J B LOCATION NAME CASH E]CHECK❑ <br /> NA ' i H <br /> ADDRESS C R DYIN <br /> A t [j <br /> ITV � <br /> TAT Z CO. CITY STATE ZIP CO. PO 2 0 <br /> PHONE NO. PROFILE NO. CUSTOMER EPA 1 NO. <br /> P O NO. / t ) <br /> WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> PRODUCT CODE NUMBER <br /> Used oil,Ndn-RCRA Hazardous; Lubricating CA 221 <br /> Gal. <br /> Industrial CA221 Gal. <br /> Waste,Liquid Gal. <br /> Ild Mnamativ�Antinecss.NwrRCRA Ilawdw�a CA134 <br /> w�l:�c CAN Gal. <br /> 1"3In eCo,nbusEble l:9dd NO.S.NA FearlFWS <br /> 199J In Oil,pnumi�wM w,N w Gal. <br /> Oil&Water,Non-RCRA Hazardous Waste Liquid CA221 Gal <br /> Waste Solids and Sludges Each <br /> Wash Out Drum <br /> Drained Used Oil Filters Drum <br /> Non-.RCRA Hazar r Waste Solids(oily debris) CA223 Drum <br /> Empty Drums G 6 <br /> Hrs. <br /> Transportation Gal. <br /> Non Hazardous Water <br /> r' <br /> TEST:❑Clor D Tech 4000—Plan ❑Clor D Tech 1000 E]Pass E]Fail Halogen Detector/Flame Test pass, ❑Fmk Total Charges <br /> Field Service Work Description: /t <br /> Other: <br /> Other: <br /> Vacuum Services Time <br /> Off Load&art Off Load End Rehm to Yard <br /> Out of Yard on Site Off Site Consolidated Manifest <br /> i TSDF <br /> lter <br /> Evergreen Oil,Inc. Evergreen Env.Svc_ EverN.green <br /> lentine c � 31AJS 1CIark Ave.. El <br /> ❑ 6880 Smith Ave. Road 306 4193 ,CA 93711 Industry,CA 91745 .I <br /> Newark,CA 94560 Davis,CA 95926 ""�q,�����aF <br /> CAD990887418 CAD982446874 CAD982446882 CAD000097432 Greenleaf Env kl <br /> CFR. iIrc1T <br /> ❑ Evergreen Env.Svc. Evergreen Env.Svc. CFR 3474 T 1 CA 95352 <br /> 16604 S.San Pedro EJ 745 A West Betteravia 944 E.Slauson Ave. 33210 WestCA ern - 14411 <br /> Carson,CA 90746 Santa Maria,CA 93454 Los Angles, A 90011 CAUniL000 9150794587 V <br /> CAD981696420 CAD982446858 Generator certifies that fished a program to reduce the volume or <br /> Source: ❑Collection Station ❑ GOVeIrinlenY guean( &ator oo toxicityOf lcallyaocf baste to the degree determined by <br /> ❑ Marine ❑ Agricultural ❑ Industrial 1 hereby certify <br /> that l have read and have the authoritvto <br /> bind the above listed venerator to the terms on the reverse <br /> Reta)[91sample # r� side of this form. <br /> ,Z'✓/6 `�7-Ca ' /• fly /fir �.en KCE v c�T <br /> ^ivertire11' Print Name Route# Dae Generator's Signature Pnnt Name Data <br /> 4 <br />