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0 <br /> WORK ORDER/SERVICE AGREEMENT <br /> Evergreen Environmental Services N° 314851 <br /> dedicated to the protection of the environment <br /> To schedule a pickup, call Send payment ta: Sales Order# <br /> 800-972-5284 Evergreen Oil, Inc. <br /> 6880 Smith Ave.,Newark,CA EPA#CAD982413262 P.O. BOX 30517 <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 Los Angeles, CA 90030-0517 Date: — , I c o <br /> GENERATOR/JOB LOCATION BILLING INFORMATION I - <br /> �.� NAME CASH❑CHECK❑ <br /> ADDRESS N <br /> ADDRESS CU OMER CODE NO. <br /> 0 3�. J so- pZ <br /> CITY // STATE ZIP CO. CITY STATE ZIP CO. PO# <br /> jlu CQ f� <br /> PHONE NO. PHONE NO. PROFII,E NO. CUSTOMER EPA IDN O. <br /> a� <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> Used oil,Non-RCRA Hazardous Lubricating CA221 Y 70 5 Zep Gal. -a'e <br /> Waste,Liquid Industrial CA221 Gal. <br /> W �wmm Mtir quid ,Non-RCRA Ha=vdoun CA l34 Gal. <br /> RQ Waz2 ComGuaribk tigniE.N.OS.NA Cg221 <br /> iwu m ai�n,�w,im wiw lulu _ r001t8002 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; <br /> Drum <br /> Transportation or <br /> Hrs. <br /> Non Hazardous ater Gal <br /> Glycol Bulk 50/50 Gal <br /> Glycol But Cone. Gal <br /> TEST: Clor D Tech 4000Z*z62ppm ❑Clot D Tech 1000 Pass❑Fail ❑ Halogen Detector/Flame Test ❑Pass ❑Fail j <br /> Field Service Work Description: TotaT Chat ges <br /> Other: <br /> Other: <br /> Vacuum Services Time <br /> Out of Y d On Site Off Site Off Load Start Off Load End Return to Yard <br /> TS Consolidated Manifest <br /> Eve <br /> Eve6880 Smith Avreen Oil,ec ❑ RoadOg Env.Svc. ❑ Evergreen39Valentines ❑ AIS Filter <br /> Ave. ❑ <br /> Newark,CA 94560 Davis,CA 95616 Fresno,CA 93722 Indus CA 91745 <br /> CAD980887418 CAD982446874 CAD982446882 CADZIW7432 <br /> x <br /> ❑ Evergreen Env.Svc ❑ Evergreen Env.Svc. ❑ GFR ❑ CFR ❑ Greenleaf Env.Svc. <br /> 16604 S.San P 745 A West Betteravia 944 E.Slauson Ave. 33210 Western 3474 Toyon Circle <br /> Carson,CS 90 Santa Maria,CA 93454 Los Angeles,CA 90011 Union City,CA 94587 Valley Springs,CA 95352 <br /> CAD981696426 CAD982446858 CAL.000110021 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 /> Re n sample # --G y bind the above listed generator to the terms on the reverse <br /> side of this form. <br /> �fly z <br /> D ignature Print Name Route# fDate enerator's Signar Print Name Date <br />