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0 <br /> IfieWORK ORDER/SERVICE AGREEMENT <br /> Evergreen Environmental Services No L <br /> dedicated rn rhe protection.f the em tronrneor <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 /> NA NAME CASH❑ CHECK ❑ <br /> MAt <br /> ADDRESS _ ADDRESS CUSXPMER CODE NO. <br /> CITY STATE ZIP CO. CITY STATE ZIP CO. P # <br /> S-761 n4 <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 p Gal. - ^r <br /> Waste,Liquid Industrial CA221 Gal. <br /> U>WA9InmOdve Andfirc .Nmr-RCRA Hn—&.. CA134 <br /> Waz¢Li uid Gal. <br /> RQW....Coinbuetibl>Liquid,NOS.NA CA221 <br /> 1993111(od rnvumimd w'tb Rnlo ens FOOUF)02 Gal. <br /> Oil&Water.Non-RCR.A Hazardous Waste Liquid CA221 _ Gat. <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 /> Transportatio firs. 'fir i <br /> Non Haz ous Water Gal. <br /> TEST. Clor D Tech 400043p_.ppm ❑Cloy D Tech 100OLePass, ❑Fail ❑ Halogen Detector/Flame Test ILIPass ❑ Fail <br /> Field Service Work Description: Total Char.Res <br /> Other: <br /> Other: <br /> Vacuum rvices Time �) <br /> Out of ad-On Site Off Site Off Load Start 4 Off Load End Return to Y � a <br /> I <br /> F Consolidated Manifestvergreen Oil,Inc. ❑ Evergreen Env.Svc. ❑ Evergreen Env.Svc. AJS Filter880 Smith Ave. Road 30B 4139 N.Valentine 11 15131 Clark Ave. <br /> Newark,CA 94560 Davis,CA 95926 Fresno.CA 93711 Industry,CA 91745 <br /> CAD980887418 CAD982446874 CAD982446882 CAD000097432 <br /> Evergreen Env. Sv / ❑ Evergreen Env. Svc. 1:1CFR ❑ CFR ❑ Greenleaf Env. Svc. <br /> 16604 S.San Pe 745 A West Betteravia 944 E.Slauson Ave. 33210 Western 3474 Toyon Circle <br /> Carson,CA 90 6. Santa Maria,CA 93454 Los Angeles,CA 90011 Union City,CA 94587 Valley Springs,CA 95352 <br /> CAD981696 r CAD982446858 CAL0001IM21 CAL000091507 CAL000214411 <br /> Source: Collection Station ❑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 /> Re n sample # L--_�� side of this form. <br /> e <br /> Dr Signature nt Name Route# Date nerator's Signature Print Name Date <br />