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L <br /> AZA WORK ORDER/SERVICE AGREEMENT <br /> Evergreen Environmental Services NO- 200771 <br /> dedicated to the protection of the environment <br /> To schedule a pickup, call Send payment to: Sales Order#I <br /> 800-972-5284 Evergreen Oil,Inc. <br /> 6880 Smith Ave.,Newark,CA EPA#CAD982413262 P.O. BOX 678252 <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 Dallas,TX 75267-8252 Date: <br /> GENERATOR/JOB LOCATION BILLING INF ATION <br /> NA > Y NAME CASH❑ CHECK❑ <br /> # <br /> AQDWS C /..,U� �D t CU TO R_ <br /> C G 4_TQ W 6O. CITY STATE ! Z CO. PO# <br /> PHONE PHONE NO. PROFILE NO. T <br /> PRODUCT WASTE MANIFEST QUANTTTY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> Used oil,Non-RCRA Hazardous Lubricating CA221 Gal, <br /> Waste,Liquid Industrial CA221 Gal. <br /> w�a01 ve AntiRwae,Nm-RCRA Ha u. CA134 Gal. <br /> RQ Was¢Combutibk Liquid.N.O.S.NA CA221 <br /> 1993 nl O,1 conmmina¢d wi0 halo ens FH01/F002 Gal. <br /> Oil&ste SWater,Non-RCRA Hazardous Waste Liquid CA221 Gal, <br /> W_ Solids and lu rGal.Drai d Used Oil 'Iters Non-RCRA Hazardous Waste Solids(oily debs)Empty DrumsTransportation Non Hazardous Water -7TEST:❑ Clor D Tech 4000_ppm ❑Clor D Tech 1000❑Pass ❑Fail ❑ Halogen Detectail Z O <br /> Field Service Work Description: Total Charges <br /> Other: <br /> Other: <br /> Vacuum Services Time <br /> Out of Yard On Site Off Site_Off Load Start Off Load End Return to Yard <br /> TSDF LJ Consolidated Manifest <br /> ❑ Evergreen Oil,Inc. ❑ Evergreen Env.Svc. ❑ Evergreen Env.Svc. ❑ AIS Filter <br /> 6880 Smith Ave. Road 3C Fresno, <br /> Valentine Indus Clark Ave. <br /> Newark,CA 94560 Davis, 24 95926 Fresno,CA 93711 Industry, 9 91745 <br /> CAD980887418 CAD982446874 CAD982446882 CAD000097432 <br /> Evergreen Env.Svc. Evergreen Env.Svc. ❑ CFR CFR Greenleaf Env.Svc. <br /> 16604 S.San Pedro 745 A West Bettemvia 944 E.Slauson Ave. 1:133210 Western 3474 Toyon Circle <br /> Carson,CA 90746 Santa Maria,CA 93454 Los Angeles,CA 90011 Union Cityry CA 94587 Valleyy Spprings,CA 95352 <br /> CAD981696420 CAD982446858 CAL000110021 CALOW091507 CA 14411 <br /> Generator certifies that it has established a program to reduce the volume or <br /> Source: ❑Collection Station ❑Government 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 /> bind the above listed generator to the terms on the reverse <br /> Retain sample, aide Wfl1 form. <br /> &A&V= O <br /> Driver Sig u nt ame Route # Date Gener is Signature Print Varne Date <br />