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WORK ORDET- --ERVICE AG <br /> 0 Evergreen Environental Services <br /> • dedicated to the protection of the environment N° 123841 <br /> To schedule a pickup, call Send payment to: Sales Order# <br /> 800-972-5284 Evergreen Oil, lac. <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: 4,Lf a <br /> GENERATOR/JOB LOCATION BILLING INFORMATION <br /> N ME NAME <br /> CASH CHECK <br /> ADDRESS # <br /> ADDRESS CU TO E COPE NO. <br /> S � <br /> CI STATE ZIP CO. CITY STATE ZIP CO. PO# <br /> PHONE N �r <br /> PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. <br /> PRODUCT WASTE MANIFEST <br /> CODE NUMBER QUANTITY UNITS PRICE AMOUNT <br /> Used oil,Non-RCRA Hazardous Lubricating CA221 W S'•O O Gal. <br /> Waste,Liquid Industrial CA221 Gal. <br /> Liquidoi�Anufre .Non-RCRA Har;Wd CA 134 <br /> Gal. <br /> RQ Waste Combustible Liquid.N.O.S.NA CA221 <br /> 1993 Ill Oil contaminated witb halo ens F001/F002 Gal. <br /> Oil&Water,Non-RCRA Hazardous Waste Liquid CA221 Gal <br /> Waste Solids and Sludges Gal. <br /> Wash Out 919 Each <br /> Drained Used Oil Filters Drum <br /> Non-RCRA Hazardous Waste Solids(oily debris) CA223 Drum <br /> Empty90or <br /> Drum <br /> Transp <br /> Hrs. <br /> Non Her Gal. <br /> TEST: ch 4000�_wrn Clor DTech 1000 Pass❑Fail Halogen Detector/Flame Test Pass []Fail <br /> Field Service Work Description: <br /> Total Charges <br /> Other: <br /> i <br /> Other: <br /> Vacuum Serv' es Time <br /> Out of Y -onsite Off Site Off Load Start /� <br /> Off Load End Retum to Yard <br /> TS Consolidated Manifest <br /> Evergreen Oil,Inc. ❑ Evergreen Env.Svc. ❑ Evergreen Env.Svc. ❑ AJS 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 /> CAD980887418 CAD982446874 CAD982446882 CAD000097432 <br /> Evergreen Env.Svc. ❑ Evergreen Env.Svc. ❑ CFR ❑ CFR ❑ Greenleaf Env.Svc. <br /> 16604 S.San Ped 745 A West Betteravia 944 E.Slauson Ave. 33210 Western 3474 Toyon Circle <br /> Carson,CA 907 Santa Maria,CA 93454 Los Angeles,CA 90011 Union City,CA 94587 Valley Springs,CA 95352 <br /> CAD9816964 CAD982446858 CAL000110021 CAL000091507 CALOW214411 <br /> Source: Collection Station Ll 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 ❑ ndustrial generator to be economically practicable. <br /> I hereby certify that I have read and have the authority to <br /> R in sample # ( bind the above listed generator to the terms on the reverse <br /> side of this form. <br /> L /.41. <br /> 3 0� <br /> D ' er Signature Print Name Route# Oate enerator's Signature Name Dat <br /> - <br />