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,.� WORK ORDEWSERVICE AGREEMENT <br /> Evergreen Environmental Services 21 5461 4 <br /> dedicated to the protection of the em it .:e a <br /> To schedule a pickup, call Sales Order # <br /> 800-972-5204 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 INFORMATION <br /> NAME, NAME CASH ❑ CHECKAt <br /> ❑ <br /> ADDRESS - ADDRESS CUSTOMER CODE NO. <br /> CITY STATE ZIP CO. CITY STATE ZIP CO. PO# <br /> i <br /> PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> Used oil,Non-RCRA Hazardous Lubricating CA221 -1 ` Gal. - <br /> Waste.Liquid Industrial CA221 Gal. <br /> UscJ A=iw Andrreeze.Non-RCRA Hv udoue <br /> wane t,wa CA 134 Gal. <br /> Rot Waue Combustible liquid.N.O.S.NA CA-1 <br /> 1991 III Oil contamLuued with halogens) F001/FW3 Gal. <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 Hazardous Waste Solids(oily debris) CA223 Drum <br /> Empty Drums Drum <br /> TransportationHrs. <br /> Non Hazardous Water Gal. <br /> TEST:❑ Clor D Tech 4000—ppm ❑Clor D Tech 1000❑Pass❑Fail ❑ Halogen Detector/Flame Test ❑Pass ❑Fail <br /> Field Service Work Description: <br /> Other: <br /> Other: <br /> Vacuum Services Time <br /> -0ut of Yard On Site - Off SiteOff Load Start Off Load End Remm to Yard - <br /> TSDF F1 Consolidated Manifest <br /> Evergreen Oil,Inc. �.Evergreen Env.Svc. ❑ Evergreen Env.Svc. ❑ AJS Filter F-1 - <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 /> 11 Evergreen Env.Sc. El <br /> Env.Svc. ❑ CFR ❑ CFR Greenleaf Env.Svc. <br /> 16604 San P ro 745 A West Betteravia 944 E. Stinson Ave. 33210 Western 3474 Toyon Circle <br /> Carson,S.CA 9 46 Santa Maria,CA 93454 Los Angeles,CA 90011 Union City,CA 94587. Valley Springs,CA 95352 <br /> CAD98169 0 -CAD982446858 CAL000110021 CAL000091507 CAL00021441 I <br /> = <br /> ,Ytor certifies that it has established a program to reduce the volume or <br /> Source: l 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 [o <br /> bind the above listed generator to the terms on the reverse <br /> Retain sample # side of this form. <br /> Driver Signature Print Name Route# Date Generator's Signature Print Name Date <br />