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WORK ORDER/SERVICE AGREEMENT <br /> Eve en Environmental Services 44N° 116948 <br /> / dedicated to the protection of the environowul <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 /> 16640 S.San Pedro St.,Carson,CA EPA#CAD962413262 Los Angeles, CA 90084-2457 Date: 0 <br /> GENERATOR/JOB LOCATION BILLING INFORMATION <br /> NAME NAME CASH❑ CHECK❑ <br /> T A. 4 # <br /> ADDRESS ADDRESS CUSTOMER CODE NO. <br /> p0 <br /> CITY STATE ZIP CO. CITY STATE ZIP CO. POaivn <br /> HONE N . PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS4PRICE AMOUNT <br /> CODE NUMBER t �� <br /> Used oil,Non-RCRA Hazardous Lubricating CA221 ZZSrf$4� t,—ap Gal. . pQ <br /> Waste,Liquid Industrial CA221 Gal.Used AuloaKKive Amifrtere.Non-RCRA NvvMus CA134 p {�r� Gal. <br /> WeacL id <br /> RQ W-le Combustible biquid.N.0 S.NA CA221 Gal. <br /> 1993111 Oil wnumineled wM bat Mi/rlla2 <br /> Oil&Water,Non-RCRA Hazardous Waste Liquid CA221 Gal. <br /> Waste Solids and Sludges Gal. <br /> Wash Out Each <br /> Drained Used Oil Filters Drum <br /> Non-RCRA Hamnlous Waste Solids(oily debris) CA223 Drum <br /> Empty Drums Drum <br /> Transportation Hrs. <br /> Non He MIA Water Gal. <br /> TEST: Clor D Tech 4000�ppm E]Clor D Tech 1000 Pass E]Fail ❑ Halogen Detector/Flame Test Pass ❑Fail ZZ>, .—$A, <br /> Field Service Work Description: Total Charges <br /> Other: <br /> Other: <br /> Vacuum Services Time <br /> Out of On Site Off Site_Off Load Slap 4 Off Load End Retu n Yard <br /> TS F Consolidated Manifest <br /> Ever en Oil,Inc. Evergreen Env.Svc. Evergreen Env.Svc. AIS Filter <br /> 6880 Smith Ave. ❑ Rued 30B ❑ 4139 N.Valentine ❑ 15131 Clark Ave. <br /> Newark,CA 94560 Davis,CA 95926 Fresno,CA 93711 Industrryy CA 91745 <br /> CAD980887418 CAD982446874 CAD982446882 CAL M97432 <br /> ❑ Evergreen Env. Evergreen Env.Svc. ❑ CFR - 1:1CFR ❑ Greenleaf Env.Svc. <br /> 16604 S.San PJr.Qro 745 A West Betteravia 944 E.Slauson Ave. 33210 Western 3474 Toyon Circle <br /> Carson,CA 9VF46 Santa Maria,CA 93454 Los Angeles,CA 90011 Union City,CA 94587 Valley Springs,CA 953.52 <br /> CAD981696 0 CAD982446858 CAL000110021 CAL0001507 CAL000214411 <br /> enerator certifies that it has established a program to reduce the volume or <br /> Source: Collection Station L1G <br /> Government quantity&toxicity of the hazardous waste to the degree determined by <br /> ❑Marine O Agricultural ❑ Industrial generator to be economically practicable. <br /> 1 hereby certify that I have read and have the authority to <br /> bind the above listed generator to the terms on the reverse <br /> fain sample # 3�I f side of this form. <br /> 0)9 <br /> ver Signature Print Name Route# Date eneratoi's Signature Print Name Date <br />