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WORK ORDER/SERVICE AGREEMENT <br /> Evergreen Environmental Services NO- 199849 <br /> / dedicated to the protection of the environment <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 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 /> N NAME CASH❑ CHECK❑ <br /> ADDRESS / ADDRESS CU OMER CODE NO. <br /> S S �o *Er /—,L a O Z <br /> CITY STATE ZIP CO. CITY STATE ZIP CO. PO# <br /> 4 C/h <br /> PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID N0. <br /> 7 I ( ) I e,44aapowwe <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> Used oil,Non-RCRA Hazardous Lubricating CA221 1314<iLgg Z 70 Gal. .am <br /> Waste,Liquid Industrial CA221 Gal. <br /> Used A Vive Ami me,Nan-RCRA 11—dour CA 134 Gal. <br /> wane V vid <br /> Ral Waste Combustible Liquid,N O.S.NA CA221 G.� <br /> 1991111 Oil mnta,ntiwutl seat talo em F001tF002 <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 Dmms Drum <br /> Transportation His. <br /> Non Hamr/us Water Gal. <br /> TEST:YClor D Tech 4000_ZW>_-ppm ❑Clor D Tech 1000 Pass ❑Fail ❑ Halogen DetectorMame Test ❑P ❑Fail <br /> Field service Work Description: Total Charges <br /> Other: <br /> Other: <br /> Vacuum S ices Time <br /> Out of itOn Site - Off Site Off Load Start Off Load End Return to im <br /> TS Consolidated Manifest <br /> Ever en Oil,Inc. Evergreen Env.Svc. Evergreen Env.Svc, AJS Filter <br /> 6880 Smith Ave. 3ad 0B 4139 Nom.Valentine 15131 Clark Ave. <br /> Newark,CA 94560 //! Davis,CA 95926 Fresno,CA 93711 Industry,CA 91745 <br /> CAD980887418 CAD982446874 CAD982446982 CAD000097432 <br /> Evergreen Env.Svc Evergreen Env.Svc. CFR CFR El Greenleaf Env. vc. <br /> 16604 S.San Pe 745 A West Betteravia 944 E.Slauson Ave. 1:1 33210 Western 3474 Toyon Cir <br /> Carson,CA 90 Santa Maria.CA 93454 Los Angeles,CA 90011 Union City,CA 94587 Valley Springs.C�/ <br /> CAD981, CAD982446858 CAL000110021 CAL000091507 CAL000214411 <br /> Generator cetrifles that it has established a program toreduce 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 pie # a �— side of this form. <br /> Prin <br /> X YhGIG•-Sdn� 1`19 <br /> Driver Signa re Name Route# ate enerator's Signature Print Name Date <br />