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• <br /> WORK ORDER/SERVICE AGREEMENT <br /> Evergreen Environmental Services NO 273154 <br /> / dedicated to the protection of the environment <br /> To schedule a pickup, call Send payment to: Sales.Order# �53 <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: DSS <br /> GENERATOR/JOB LOCATION BILLING INFORMATION Or r <br /> N NA CASH❑ CHECK E] <br /> tU75 /^'7/ed— S # <br /> AD SS ADRESS C TOMER CODE NO. <br /> JanaaL e <br /> C TY TATE ZIP CO. CITY / STATE ZIP CO. PO# <br /> s &' <br /> PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA to NO. <br /> $ /to- c <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> Used oil,Non-RCRA Hazardous Lubricating CA221 Gal. <br /> Waste,Liquid Industrial CA221 Gal, <br /> Uud Automadve Andfmcu.Non-RCM Henrdaus <br /> L,uid CA134 Gal. <br /> wus�e <br /> RQ Wuse Combusdhle Liquid N.O.S.NA CA221 Gal. <br /> 1993 III Oil conmmiva d nriW halo si' r001/m <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 — 60 S- UC) <br /> Non-RCRA Hazardous Waste Solids(oily debris) CA223 Drum <br /> Empty Drums Drum <br /> Transportation Hrs. <br /> Non Hazardous Water Gal. <br /> Glycol Bulk 50/50 Gal. <br /> Glycol Bulk Cone. Gal. <br /> TEST:F] Clot D Tech 40W—ppm ❑Clot D Tech 1000❑Paas ❑Fail ❑ Halogen Detector/Mame Test ❑Pass ❑ Fail <br /> Field Service Work Description: Total Charges <br /> Other: <br /> Other: <br /> Vacuum Services Time Q <br /> Out of Yard On Site Off Site_Off Load StartOff Load End—Return to Yard <br /> TSDF ❑ Consolidated Manifest <br /> ❑ Evergreen Oil,Inc. ❑ Evergreen Env.Svc. ❑ Evergreen Env.Svc. ❑ AIS Filter ❑ <br /> 6880 Smith Ave. Road 30B 4139 N.Valentine 15131 Clark Ave. <br /> Newark,CA 94560 Davis,CA 95616 Fresno,CA 93722 Industry,CA 91745 <br /> CAD980887418 CAD982446874 CAD982446882 CAD000097432 <br /> ❑ Evergreen Env.Svc. ❑ Evergreen Env.Svc. ❑ CFR 1:1CFR ❑ Greenleaf Env.Svc. <br /> 16604 S.San Pedro 745 A West Bettemvia 944 E.Slauson Ave. 33210 Western 3474 Toyon Circle <br /> Carson,CA 90746 Santa Maria,CA 93454 Los Angeles,CA 90011 Union City,CA 94587 Valley Springs,CA 95352 <br /> CAD981696420 CAD982446858 CAL000110021 CAL000091507 CAL000214411 <br /> Generator certifies that it has established a program to reduce the volume or <br /> Source: ❑ Collection Station ❑Government 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 thy terms on the reverse <br /> etain a aid this farm. <br /> Driver Si afore Print Name Route# D to nera I'S Signature Print Name Date <br />