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WORK ORDER/SERVICE AGREEMENT <br />�j Evergreen Environmental Services <br />dedicated m tire protection of the environment <br />To schedule a pickup, Call Send pa.Nment to: <br />800-972-5284 Evergreen Oil, Inc. <br />6880 Smith Ave., Newark, CA EPA# CA0982413262 P.O. BOX 678252 <br />16540 S. San Pedro St., Carson, CA EPA# CAD982413262 Dallas. TX 75267-8252 <br />rwr� rwrcnow,rA Trrl1U <br />N° 212168 <br />Sales Order # :L 7 <br />Date: !- <br />It'nNi RAa <br />WASTE <br />CODE <br />......._..� <br />NAME <br />UNITS PRICE <br />CASH ❑ CHECK E]�Sl <br />NAMEy 1 �; <br />CA221 <br />2 7 <br />Gal. <br /># <br />Waste. Liquid Industrial <br />CA221 <br />ADDRESS <br />Gal. <br />I C UMER tuy>: NU. <br />Uua Amamgivt Amirrre Van-RCRi Hv.rd-1 <br />Knv L mJ <br />CA134 <br />Gal. <br />CIT STATE <br />ZIP CO. <br />CITY <br />STATE ZIP CO. <br />PO At <br />oil & Water. Nun-RCRA Hazardous Waste Liquid <br />�t.7to <br />Gal. <br />PHONE NO. <br />PHONE NO. <br />Gal. <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />Each <br />Drained Used Oil Filters <br />PRODUCT <br />WASTE <br />CODE <br />MANIFEST QUANTITY <br />NUMBER <br />UNITS PRICE <br />AMOUNT <br />Used oil. Nun-RCRA Hazardous Lubricating <br />CA221 <br />2 7 <br />Gal. <br />Waste. Liquid Industrial <br />CA221 <br />Gal. <br />Uua Amamgivt Amirrre Van-RCRi Hv.rd-1 <br />Knv L mJ <br />CA134 <br />Gal. <br />A, KineCnmam�iMe Li4uia.](1 S.\'.4 <br />iws ui ioii.�oumin .itn tit <br />CA221 t <br />- <br />Ga,. <br />oil & Water. Nun-RCRA Hazardous Waste Liquid <br />CA221 <br />Gal. <br />Waste Solids and Sludges <br />Gal. <br />Wash Out <br />Each <br />Drained Used Oil Filters <br />Drum <br />Non-RCRA Hazardou este Solids (oily debris) <br />CA223 <br />Drum <br />Empty Draw <br />- <br />Drum <br />Transportation <br />Hrs. <br />Nun Hazar u. Water <br />Gal, <br />TEST: Clot D Tech 40( �' ppm ❑ Clor D Tech 1000 <br />Pass ❑ Fail ❑ Halogen Detector <br />lame st ❑Pass ❑ Fail <br />< �� <br />Field Service Work Description: <br />�tIW� Cllilrg L•� <br />Other: <br />Other'. <br />Vacuum eniuu Time <br />J/ <br />Out of and On Site Off Site <br />Off Load Stan Off Load End <br />Return to Yard <br />TSF <br />,L -J( Evergreen Oil. Inc. <br />6880 Smith Ave. <br />Newark. CA 94560 <br />c AD9ho88741 <br />Evergreen Env. Svc. <br />Road 30B <br />Davis. CA 95926 <br />CAD982446874 <br />U Consolidated <br />❑Evergreen Em. Sec AJS Filt <br />4139 N. Valentine 15131 C <br />Fresno. CA 93711 Inclu:tn <br />CAD98'_446882 CAIANNNN17412 <br />Evergreen Env Syt. ❑ E'ergreen Env. Svc. CFR CPR t Cnenlral F.m. �2. <br />16604 S. S:m P ern 745 A West Betteravia ❑ 944 II. Shusun Ace. L 33210 Western L.J 3474 Toyon Circle <br />Cown, CA v 46 Smtu Maria, CA 93454 Lus Anggeles. CA 90011 Union City. CA 94587 Vallev Springs. CA 95352 <br />CAD98169 0 CAD982446858 CALOMI 10021 \1 (AAA i11 C:AI iKAI, 14411 <br />Grnerenn aitow, that it ha. cswhh,hvd :i program w reduce the %Nome w <br />Source: COIIeCIIOn Station '❑ Government ga:uail) & hiSiciq of the h.v:udou, sct.tr ihv Jegrcc determined h2 <br />Marine ❑ Agricultural ❑ Industrial gemraun to b eeonoITolol } practicable. <br />_ I herebc certif\ that I have read and have the authorit\ to <br />G bind the above listed generator to the terms nn the reverse <br />in Sample # % C— j side of this form. <br />/ l�,a A,�� �e ,OfbN�- <br />veer Sienawre Print Name Route 41 ate enerator's Signature Print Name Date <br />