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A1.4NVORK ORDER/SERVICE' AGREEMENT <br /> Evergreen Environmental Services �� 185716 <br /> drdicofed to the prorecriun of the oo iro mrent <br /> To schedule a pickup, call Send pa. nrn nw to: Sales Order # <br /> 800-972-5284 Evergreen Gil. Inc. - <br /> 6880 Smim A,e..Newark,CA EPA#CAD982413262 P.O. BOX 678'_52 <br /> - S. San Pedro St-. Carson, CA EPA#CA0982413262 Dallas. TX 72'_67-825-' Date' Z'S <br /> -k rORIJOB LOCATION BILLING INFOR_M4TION <br /> �a NAME CASH❑ CHECC <br /> _ # <br /> ADDRESS CUSTOMER CODE NONO <br /> toss' L 4OZ <br /> STATE ZIP CO. CITY STATE ZIP CO. PO# <br /> LHONEE NO. PHONE NO. PROFILE NO. CUSTOMER EPI, ID N0. <br /> PRODUCT WASTEMNUMBERANIFEST <br /> CODE QUANTITY UNITS PRICE AMOUNT <br /> Used oil.Non-RCRA Hazardous Lubricating CA221 q IZ ZZO Gal. . 30 <br /> Waste, Liquid Industrial CA221 Gal. <br /> OSN dummmi.e%rtifreem,Non-RCR,1 Hume:ws Gal <br /> w.�ec and CA134 <br /> RQ W m'rc Cmna:wTle Hyoid.N.O.S.NA CA121 <br /> 1993 m o,1 w.,rndnwu.d, [.cno FWl/1R)02 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 Dtu - <br /> j Transportation <br /> Non Hazar us Water Gal. - <br /> TEST Z Clor D Tech 4000.4-00ppm ❑Our D Tech ION Pass❑Fail ❑ Halogen Detector/ ame Test ❑Pass ❑Fail Jq <br /> Field Service Work Description: Total Charlzes <br /> Other: <br /> Other: <br /> Vacuum S ices Time <br /> Out of d On Site Off Site Off Load Start Off Load End Return to Yard <br /> TS Consolidated Manif t <br /> Evergreen Oil,Inc. ❑ Evergreen Env.Svc. Evergreen Env.Svc. AJS Filter <br /> 6880 Smith Ave. Road 30B 4139 N.Valentine 1:115131 Clark Ave. <br /> Newark.CA 94560 Davis,CA 95926 Fresno,CA 93711 industry.CA 91745 <br /> CAD9868874IS CAD982446874 CAD982446882 CAD000097432 <br /> Evergreen Em'. Sv Evergreen Em'.Svc. ❑ CFR ❑ CFR <br /> 16604 S.Sao Pe 745:A West--a— 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 CAD982446858 CAL000110021 CAL000091507 CAL000214411 <br /> Generator cettifies that it has established a prop am to reduce the volume or <br /> Source: Collection Station LJ Government quantiry&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 fisted generator to the terms on the reverse <br /> R in sample # G y side of this form. <br /> $ ZS 1G <br /> DF Signature Print Name Route# & <br /> bate, enera or's Signature Jnt Name Date <br />