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J • • <br /> WORK ORDER/SERVICE AGREEMENT <br /> Evergreen Environmental Services N° 3 31112 <br /> dedicated to the protection of the environment <br /> To schedule a pickup, call Send payment to: Sales Order �t�lo <br /> 800-972-5284 Evergreen Oil, Inc. <br /> 6880 Smith Ave., Newark,CA EPA#CAD982413262 P.O. BOX 30517 ���� <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 Los Angeles, CA 90030-0517 Date: VWZ/ io <br /> GENERATOR/JOB LOCATION BILLING INFORMATION �I <br /> 4144VVVJ !EQ N N <br /> CASH E] CHECK❑ <br /> ADDRESS ;AD7DRESS CUST MER CODE NO. <br /> CITY STATE Z CO.:: STATE ZIP CO. PO# <br /> MUNE N NO. PROFILE NO. CUSTOMER EPA lD NO. <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> Used oil,Non-RCRA Hazardous Lubricating CA221 Gal. <br /> Waste,Liquid Industria! CA221 Gal. <br /> Wase Li ui vc Antitrcere,Nm-RCRA 11 n .s CA I34 G81. <br /> RQ Wmm Cambustiblc liquid N.OS.NA <br /> CAN <br /> 1"3 m oa�m,um;drm ww M...) movrmz Gal. <br /> Oil&Water,Non-RCRA Hazardous Waste Liquid CA221 Gal, <br /> Waste Solids and Sludges Gal <br /> Wash Out <br /> Each <br /> Drained Used Oil Filters Drum <br /> Non-RCRA Hazardous Waste Solids(oily debris) CA223 Drum <br /> Empty Drums <br /> Drum <br /> Transportation <br /> Hrs. <br /> Non H;Bulk <br /> ous W r Gal. <br /> Glyco50/50 Gal <br /> GlycoConc. GalTESTlot D Tech ppm ❑Clor D Tech 1000 Pass ❑Fail ❑ Halogen Detmtor/Flame Test ass ❑Fail ..� <br /> Field Service Work Description: Total Charges <br /> Other: <br /> Other: <br /> Vacuum S ices Time Q <br /> Out of On Site Off Site Off Load Start Off Load End Return to Yard <br /> TS Consolidk6d Manif st <br /> Evergreen Oil,Ina Evergreen Env.Svc. ❑ Evergreen Env.Svc. ❑ AIS Filter ❑ <br /> 6880 Smith Ave. Road 30B 14139N.Valentine 15131 Clark Ave. <br /> Newark,CA 94560 Davis,CA 95616 Fresno,CA 93722 Industry,CA 91745 <br /> CAD980887418 CAD982446874 CAD982446882 CAD000097432 <br /> ❑ Evergreen Env.S ❑ Evergreen Env.Svc. ❑ CFR CFR.. Greenleaf Env.Svc. <br /> 16604 S.San P o 745 A West Betteravia 944 E.Slauson Ave. 33210 Western 3474 Toyon Circle <br /> Carson,CA 90 Santa Maria,CA 93454 Los Angeles,CA 90011 Union City,CA 94587 Valley Springs,CA 95352 <br /> CAD98169 CAM82446858 CAL000110021 CAL000091507 CAL000214411 <br /> Source: Collection Station L)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 ❑ 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 /> R to n sample # t-' t side of this form. <br /> D er ignature nt Name Route# D Generator's Sign Print Name Date <br />