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. i ` r WORK ORDER/SERVICE AGREEMENT, <br /> ver reen Environmental Services N� 97062 <br /> ° dedicated to the protection of the environment <br /> To schedule a pickup, call Send payment to: Sales Order#'& Z05-= <br /> 800-972-5284 Evergreen Oil, Inc. <br /> 1 6880 Smith Ave., Newark,CA EPA#CA0902413262 Dept. 2457 - <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 Los Angeles, CA 90084-2457 Dater JII/S'l� <br /> GENERATOR/JOB LOCATION BILLING INFORMATION <br /> NAME NAME CASH❑CHECK❑' <br /> a # <br /> AD RES ADDRESS CUSTOMER CODE NO. <br /> 3CUST02R <br /> 1JJ <br /> Ct'!'Y STATE ZIP CO. CITY STATE ZIP CO. <br /> D7 <br /> PHONE NO. PHONE NO. PROFILE NO. EPA m NO. <br /> S 167 <br /> PRODUCT WASTE MANIFEST <br /> CODE NUMBER QUANTITY UNITS PRICE AMOUNT <br /> Used oil.Non-RCRA Hazardous Lubricating CA221 ,ipGal. j e p."a <br /> Waste,Liquid Industrial CA221 Gal. <br /> wwv Lim,�tl ive A nfirt u.Non-RCRA H-md CA 134 Gal. <br /> RQ Wag cmnbusiiMe liquid,N.O.S.NA CA221 <br /> .1 in �am,mimua v.,m W rooln002 Gal. <br /> Oil&Water.Non-RCRA Hazardous Waste Liquid CA221 Z D 4zO Gal. 1,4f.S'ta <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 Hrs. <br /> Non Hazardous Water Gal. <br /> TEST:Clor D Tech 4000ZVL—ppm ❑Clor D Tech I000tWass❑Fail ❑ Halogen Detector/Flame Test ❑Pns/n Fail Z5:.— <br /> Field <br /> s:yoFeld Service Work Description: Total Charges <br /> Other: <br /> Other: <br /> Vacuum Services Time <br /> Out of Yard On Site Off Site Off Loa=Consolidated <br /> (to — <br /> TSDF <br /> j�Evagmn Oil,Inc. 1:1Evergreen Env.Svc. E] Evergreen Env.Svc. ❑ AJS Filter ❑ <br /> 6880 Smith Ave. Road 308 4193 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 CFR Greenleaf Env.Svc. <br /> 16604 S.San Pedro 745 A West Betteravia 944 E.Slauson Ave. 0 33210 Western 3474 Toyon Circle <br /> Carson,CA 90746 Santa Maria,CA 93454 Los Angeles,CA 90011 Union City,CA 94587 Valleyy Springs,CA 95352 <br /> CAD981696420 CAD982446858 CAL000110021 CAL000091507 CAL000214411 <br /> Generator ,wrtirres that it has established a program to reduce the volume or <br /> Source: W'Collection Station ❑Government quantity&toxicity of the hazardous waste to the degree determined by <br /> ❑Marine ❑ A 'cultural ❑ Industrial generator to be economically practicable. <br /> I hereby certify that I have read and have the authority to <br /> Re n sample #_q bind the above listed generator to the terms on the reverse <br /> y e 1 side of this form. <br /> iQ IdS bZ <br /> D ' er Signature Print Name Route# Date en or's Sig azure Print Name D e <br />