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• • <br /> 4 WORK ORDEWSERVICE AGREEMENT <br /> Evergreen Env. ,.amental Services N° 255788 <br /> / dedicated to the protection of the environment /� (� <br /> To schedule a pickup, call Send payment to: �� /� �` ?`'y j`Q <br /> PaYm Sales r�ei-# c <br /> 800-972-5284 Evergreen Oil, Inc. �y <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 i7 CASH❑CHECK❑ <br /> /DD -.x'7 l/ ADDRESS . r> �__ 'f Cj3ST9lW�R E�jO <br /> S T TE z�eCO. Cp" < STAX �Ie O. PO# <br /> '�f>r, C, �SZC.7 <br /> PHON -NO.,/�`- ✓ <br /> PHONE NO. PROFILE NO. 11' U�TOMER EPA,ID N� <br /> /PRODUCT/ WASTE MANIFEST QUANTITY UNITS PRICE r ,•tAMODUNT U.Y <br /> CODE NUMBER <br /> Used oil,Non-RCRA Hazardous Lubricating CA221 Gal. <br /> Waste;Liquid Industrial CA221 Gal. <br /> W LAL dive An,ifi¢u.Nan-RCRA R.d CA l34 Gal. <br /> RQ W1anm CmMleZN.OS.NA CA221 <br /> 2 <br /> 5 01mti . i. <br /> hal ev F !,T ln2 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 /> Transportation Hns. <br /> Non Hazardous Water Gal. <br /> TEST:❑ Clor D Tech 4000—ppm ❑Clor D Tech IWO❑Pass❑Fail ❑ Halogen Detector/Flaw Test ❑Pass ❑Fail J <br /> Field Service Work Description: Total Charges <br /> Other: <br /> Other: <br /> Vacuum Services Time <br /> Out of Yard On Site Off Site Off Load Start Off Load End Return to Yard <br /> TSDF ❑ Consolidated Manifest <br /> ❑ Evergreen Oil,Inc. ❑ Evergreen Env.Svc. Evergreen Env.Svc. ❑ A1S Filter <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 /> Evergreen Env.Svc. Evergreen Env.Svc. CFR FR ❑ Greenleaf Env.Svc. <br /> 16604 S.son Pedro 745 A West Betteravia 944 E.Slauson Ave. 3210 Western 3474 Toyon Cycle <br /> Carson,CA 90746 Santa Maria,CA 93454 Los Angeles,CA Union City,CA 94587 Valleyy Spprin s,CA 95352 <br /> CAD981696420 CAD982446858 CALOOO 110021 CAL000091507 CALO(10214411 <br /> Source: C3 Collection Station LJ 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 /> Retain sanioe # side of th' form. <br /> Driv r Signature rint Name Route# Date Generator's Signature Print Name Date <br /> i <br />