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WORK ORDER/SERVICE AGREEMENT <br /> Evergreen Environmental Services NO- 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#CAD962413262 Dept 2457 C6 1 g <br /> 16540 S.San PedroSI.,Carson,CA EPA#CAD982413262 Los Angeles,CA 90084-2457 Date* <br /> GENERATOR/JOB LOCATION BILLING INFORMATION <br /> NA NAME CASH❑CHECK❑ <br /> Lai t N <br /> ADDIYtS— ADDRESS CUT MER CODE NO. <br /> CI y STATE ZIP CO. CITY STATE ZIP CO. � <br /> CA .71 Z Ifo <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 LubricatingCA 221 Gal. qk T.Sv <br /> Waste,Liquid Industrial CA221 Gal. <br /> Us4 Awamdive M. <br /> m Nm k_Flam,aour CA 134 Gal. <br /> RQ3 a1 eCambuuMc Liqui4NO5.NA CA41 Gal. <br /> 199J 111 Oil cw,mm,n U with hil FCOIff002 <br /> Oil&Water,Non-RCRA Hazardous Waste Liquid CA221 Gal. <br /> Waste Solids and Sludges Gal. <br /> Wash Om Each <br /> Drained Used Oil Filters Drum <br /> Non-RCRA Hazardous Waste Solids(oily debris) CA223 Drum <br /> Empty Drums Drum <br /> Transportation Hrs. <br /> Non Hazardous Water G <br /> al <br /> TEST: Clot D Tech 4000ZQOIPpm ❑ Clor D Tech 1000 Pass ❑Fail ❑ Halogen Deteetor/H a Test HP�sE] / 90 <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 Stan ofidatedManifest <br /> to Yard /Q 0 <br /> TSDF ConsN?fvergreen Oil,Inc. Evergreen Env.Svc.. Evergreen Env.Svc. ❑ <br /> LL-1 6880 Smith Ave. Road 30B ❑ 4193 N.Valentine 15131 Clark Ave.. <br /> Newark,CA 94560 Davis,CA 95926 Fresno,CA 93711 Industry,CA 91745 <br /> CAD980887418 CAD982446874 CAD982446982 CAD000097432 <br /> Evergreen Env.Svc.❑ ❑ Evergreen Env.Svc. ❑ CFR ❑ CFR. Greenleaf Env.Svc.16604 S.San Pedro 745 A West Betteravia 944 E.Slausou Ave. 33210 Western 3474 rayon Circle <br /> Carson,CA 90746 Santa Maria,CA 93454 Los Angeles,CA 90011 Union City,CA 94587 Valley Springs,CA 95352 <br /> CAD981696-420 CAD982446858 CAL000110021 CAL000091507 CAL000214411 <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 /> El Marine ❑ Agricultural ❑ Industrial generator to be economically practicable. <br /> 1 hereby certify that I have read and have the authority to <br /> 1 bind th a ve is enerator to the terms cm the reverse <br /> R nsample # ' sideof ' fo <br /> 1 ),OL <br /> Dri r Si nature Print Name Route# Date ener t s lima ure Print Name Date <br />