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WORK ORDER/SERVICE AGREEMENT <br /> Evergreen Environmental Services N-0344977 <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 P.O. BOX 30517 <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 Los Angeles, CA 90030-0517 Date.it— <br /> GENERATOR/JOB LOCATION BILLING INFORMATION <br /> NAME NAME CASH❑ CHECK❑ <br /> t <br /> ADDRESS ADDRESS CUSyTOMER CODE NO. <br /> STATE ZIP . CO. CITY STATE ZIP CO. PO# <br /> < <br /> PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA to NO. <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> Used oil,Non-RCRA Hazardous Lubricating CA221 J7(pZla! Z Gal. L`r-t <br /> Waste,Liquid Industrial CA221 Gal. <br /> W e u o id <br /> RQ <br /> Anuaeeu.Non-RCRA Hewdoue CA 134 <br /> Gal. <br /> RQ Was.Combustible I Iuid.N.O.S.NA CA221 <br /> 1993 111 Oil cone ntrd wiN hWo enc F00VFa02 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(oil debris) CA223 Drum <br /> Empty Drums - <br /> Drum <br /> Transportation Hrs. EE <br /> Non Hazardous ater GM Glycol Bulk 50/50 iGGlycol Bul Cone. 77''�''"'� rTEST: our D Tech 4000�ppm ❑Clor D Tech 1000 Pass❑Fail ❑ Halogen Detector/Flame Test ❑Pass Field Service Work Description: <br /> 1 <br /> t <br /> Other <br /> i <br /> Other: L ;_,. ,, C 0 1 <br /> Vacuum Services Time i <br /> Out ofjfazd On Site Off Site_Off Leads= Off Load End Remm to Yard <br /> TS F Consolidated Manifest ! <br /> Evergreen Oil,Inc. ❑ Evergreen Env.Svc ❑ Evergreen Env.Svc. ❑ AJS Filter El !J <br /> 6880 Smith Ave. Road 30B 4139 N.Valentine 15131 Clark Ave. <br /> Newark,CA 94560 Davis,CA 95616 Fresno,CA 93722 Industry,CA 91745 —�O ✓` <br /> CAD980887418 '` CAD982446874 CAD982446982 CAD000097432 --"` <br /> Evergreen ❑ Evergreen Env.Svc. ❑ CER ❑ CFR ❑ Greenleaf Env.Svc. <br /> 16604 S.S 745 A West Betteravia 944 E.Slauson Ave. 33210 Western 3474 Toyon Circle <br /> Carson,CA/946 Santa Maria,CA 93454 Los Angeles,CA 90011 Union City,CA 94587 Valley Springs,CA 95352 <br /> CAD98169 CAD982446858 CAL000110021 CAL000091507 .CAL000214411 <br /> Source: Collection Station ❑Government Generator certifies that it has established a program to reduce the volume or <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 I have read and have the authority to <br /> "'rbind the above listed generator to the terms on the reverse <br /> Retain sample # v G side of this form. <br /> Driver Signature Print Name Route# I Date enerator's Signature Print Name Date <br /> I <br />