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s 0 <br /> WORK ORDER/SERVICE AGREEMENT <br /> Evergreen Environmental Services N° 278571 <br /> dedicated to the protection of the environment Q <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 T <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 Dallas,TX 75267-8252 Date:T� <br /> GENERATOR/JOB LOCATION BILLING INFORMATION <br /> NAME CASH❑CHECK❑ <br /> # <br /> ADDRESS ADDRESS C TOMER CODE NO. <br /> CI STATE ZIP CO. CITY STATE ZIP CO. PO# <br /> GB `L(o <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 (,� Gal. S.iD <br /> Waste,Liquid Industrial CA221 Gal. <br /> W Aumma ve Mu ,Non-RCRA Hvs,dwa CA134 Gal. <br /> RQ Wa Comboe461e tiV N.O.S.NA r 21 <br /> iW3m Oil wnluoio niN Wlo FWI/FW2 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 His. <br /> Non Hazardous ter Gal. <br /> Glycol Bulk 50150 Gal. <br /> Glycol Bu Cone. Gal. <br /> TEST:Vf Clor D Tech 4000 pm ❑Clor D Tech 1000 1 6pass❑Fail ❑ Halogen Detectm[Aame TestKP,sC] ail <br /> Field Service Work Description: Total Charges <br /> Other: <br /> Other: <br /> Vacu ervices Time C� <br /> Out o Yard Oo Site Off site Off Load Start Off Load End Return ro Yard <br /> J <br /> TS F Consolidated Manifes <br /> EveS Filter <br /> 6880th Ave.c. ❑ Road 30B Env.Svc. ❑ Ever4139 N.Valentinen Env. s ❑ 15131 Clark Ave. <br /> Newark,CA 94560 Davis,CA 95616 Fresno,CA 93722 Industry,CA 91745 <br /> CAD986gg7411 CAD982446874 CAD982446882 CAD000097432 <br /> ❑ Ev6C S.San 0, <br /> S o ❑ 745 A West Betteravia ❑ 44 E.Stinson Ave. ❑ 3CFR C 210 Western ❑ 3474 eaf nnCircle <br /> Carson,CA 46 Santa Maria,CA 93454 Los Angeles,CA 90011 Union City,CA 94587 Valley Spnn , <br /> CAD9816964 CAD982446858 CAL000110021 CAL000091507 CALOW14411 <br /> Source: Collection Station C1 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 /> 10 Marine ❑ Agricultural ❑ Industrial generator to be economically practicable. <br /> I hereby certify that I have read and have the authority to <br /> e inample # Z bind the above listed generator to the terms on the reverse <br /> side of this form. ,gyp <br /> e-� 1 /C� GU g"l 2- <br /> r Signature Print Name Route# Date nerator's Signature Print Name Date <br />