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4 WORK ORDER/SERVICE AGREEMENT <br /> ld Evergreen Environmental Services W 94634 <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 <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 Los Angeles, CA 90084-2457 Date: <br /> GENERATOR/JOB LOCATION BILLING INFORMATION <br /> NAME - NAME CASH❑ CHECK❑ <br /> KESS ADDRESS CUSTOMER CODE NO. <br /> CITY STATE ZIP CO. CITY STATE ZIP CO. PO#, <br /> PHONE NO. PHONE NO. PROFH.E NO. CUSTOMER EPA ID NO. <br /> PRODUCT WASTE MANIFEST QUANTITY UNITSPRICE AMOUNT <br /> CODE NUMBER <br /> Used oil,Nan-RCRA Hazardous Lubricating CA221 `..1 / I _ ;� .5 +<: Gal. <br /> Waste,Liquid Industrial CA221 Gal. <br /> UW Aam ve Antiamre,Nw Fi nms s <br /> W. . CA134 t .• '-7,�i - - Gal. <br /> le <br /> NO. <br /> 111 Oil my avn,iovm id.aJnS.NA ml' 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 Drawn <br /> Empty Iliums Drum <br /> Transportation Hts. <br /> Non Hazardous Water Gal. <br /> TESi Clor D Tech 4000--L-ppm ❑Cl.,D Tech 1000[RPass❑Fail ❑ Halogen D etectodF7ame 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 Start Off Load End-Return to Yard _ <br /> TSDF LS Consolidated Manifest <br /> Ever n Oil,Inc. Ever�cen Env.Svc. Eve Env.Svc. AJS Filter <br /> 68$0 Smith Ave. ❑ Road 30B ❑4193r Nom.Valentine ❑ 15131 Clark Ave. ❑ <br /> Newark CA 94560 Davis,CA 95926 Fresno,CA 93711 Industry,CA 91745 <br /> CAD980887418 CAW82446874 CAD982446882 CAD000097432 <br /> ❑ Evergreen Env.Svc. ❑ Evergreen Env.Svc. ❑ CFR 1:1CFR ❑ Greenleaf Env.Svc. <br /> m <br /> 16604 S.San Pedro 745 A West Benevia 944 E.Slauson Ave. 33210 Western 3474 Tryon Circle <br /> j Carson,CA 90746 Santa Maria,CA 93454 Los An elm,CA 90011 Union City,CA 94587 Valli Springs,CA 95352 <br /> CAD981696420 CAD982446858 CAL 110021 CAL000091507 CALM14411 <br /> SOULCe: ❑Collection Station ❑Government Generator certifies that it has established a program m m <br /> reduce the volume or <br /> quantity&toxicity of the hazardous waste to the degree determined by <br /> Ll Marine Ll Agricultural L] industrial generator to be economically practicable. <br /> I hereby certify that I have read and have the authority to <br /> bind the above nsted generator to the terms on the reverse <br /> Retain sample # side of this form. <br /> Driver Signature Print Name Route e# Date Generator's Signature Print Name Date <br />