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u # la -1 `-f <br />y <br />• WORK ORDER/SERVICE AGREEMENT <br />Evergreen Environmental Services No 200062 <br />dedicated to the protection of the environment <br />To schedule a pickup, call Send payment to: Sales Order # (8 `bO7 / <br />800-972-5284 Evergreen Oil, Inc. <br />6880 Smith Ave., Newark, CA EPA# CAD962413262 P.O. BOX 678252 -7 <br />16540 S. San Pedro St., Carson, CA EPA# CAD982413262 Dallas, TX 75267-8252 Date: <br />GENERATOR/JOB LOCATION BILLING INFORMATION <br />N <br />WASTE <br />CODE <br />MANIFEST QUANTITY <br />NUMBER <br />UNITS PRICE AMOUNT <br />CASH ❑ CHECK ❑ <br />fV>jNAME <br />a--.�-� <br />Lyjs r C,� <br />Gal. 20 je,30 <br />Waste, Liquid Industrial <br />CA221 <br />ADDRESS <br />ADDRESS <br />CA 134 <br />CU STO CODE NO. <br />n /J <br />/L IJ <br />RQ Wase Coubusdble Liquid. N.ONA <br />iW3111 Oil canuaunamd with hal.S. net <br />CA221 <br />1`00[fRio <br />Ga( <br />CITY STATE ZIP <br />' <br />CO. <br />CITY <br />STATE ZIP CO. <br />PO # <br />PHONE NO. <br />PHONE NO. <br />Wash Out <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />41 a <br />Drained Used Oil Filters <br />( 1 <br />Drum <br />I/ 7 <br />PRODUCT <br />WASTE <br />CODE <br />MANIFEST QUANTITY <br />NUMBER <br />UNITS PRICE AMOUNT <br />Used oil, Non-RCRA Hazardous Lubricating <br />CA221 <br />a--.�-� <br />Lyjs r C,� <br />Gal. 20 je,30 <br />Waste, Liquid Industrial <br />CA221 <br />Gal. <br />Uxtl <br />wa m a n;a Amomaarc Antitrceu, Nan-RCRA Hazardous <br />CA 134 <br />Gal. <br />RQ Wase Coubusdble Liquid. N.ONA <br />iW3111 Oil canuaunamd with hal.S. net <br />CA221 <br />1`00[fRio <br />Ga( <br />Oil & Water, Non-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 Hazardoys Waste Solids (oily debris) <br />CA223 <br />Drum <br />Empty Drums <br />Drum - <br />Transportatio <br />Urs. <br />Non Hazaz us Water <br />Gal. <br />TEST: Clor D Tech 4000_7—iZppm ❑ Clor D Tech lOW <br />Pass ❑ Fail ❑ Halogen Detector/Flume <br />Test Pass ❑ Fail Z,--> ie0O <br />Field Service Work Description: <br />I Total Charges <br />Other: <br />Other: <br />Vacuum Fees Time <br />Out of ard On Site Off Site <br />Off Load Stats Off Load End <br />Return to Yard <br />TSI l� Consolidated Manifest <br />Evergreen Oil, Inc. F­1Evergreen Env. Svc. ❑ Evergreen Env. Svc. � AIS Filter <br />6880 Smith Ave. Road 30B 4139 N. Valentine 15131 Clark Ave. <br />Newark, CA 94560 Davis, CA 95926 Fresno, CA 93711 Industry, CA 91745 <br />CAD986887418 CAD982446874 CAD982446882 CAD000097432 <br />Evergreen Env. S Evergreen Env. Svc. ❑CFR 1:1CFR Greenleaf Env. Svc, <br />16604 S. San P m 745 A West lietteravia 944 E. Stanton Ave. 33210 Western 3474 Tryon Circle <br />Carson, CA 90 46 Santa Maria, CA 93454 Los Angeles, CA 90(n1 Union City. CA 94597 Valley Springs, CA 95352 <br />CAD98169 CAD982446859 CAL000110021 CAL000091507 CAL000_14411 <br />Generator eettifies that it has established a program to reduce the volume or <br />Source: lCollection Station ❑ Government quantity & toxicity of the hazardous waste to the degree determined by <br />venerator to be economically practicable. <br />❑Marine L) Agricultural ❑ indUSlClal <br />y I hereby certify that I have read and have the authority to <br />Rt in sample # J G i bind the above listed generator to the terms on the reverse <br />side of this form. <br />r___ Zo3f_71015toc _-- <br />Name Route At ate anerator's Signature Print Name Date <br />