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`4to a WORK ORDER/SERVICE AGREEMENT <br /> Evergreen Environmental Services N° 8 1 6 7 1 <br /> dedicated to the protection of the environment e, <br /> To schedule a pickup, call Send payment to: Sales Order 7ZZ <br /> 800-972-5284 Evergreen <br /> 68W Smith A".,Newark, CA EPA#CAD982413262 P.O. Box 49065 —71111 c <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 San Jou.CA 95161-9065 Date- <br /> 16540 <br /> L <br /> CENERATORMOB LOCATION BILLING INFORMATION <br /> N E ff NAME CASH ❑CHECK❑ <br /> ADDRESS ADDRESS CIS OMER CODE NO. <br /> S VA 17MO <br /> CITY STATE ZIP CO. CITY STATE ZIP CO. PO �f�Z <br /> ` 9 Z a <br /> HONE O. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. s <br /> ll0'6- <br /> WASTE MANIFEST <br /> PRODUCT CODE NUMBER QUANTITY UNITS PRICE AMOUNT <br /> Used oil,Non-RCRA Hazardous Lubricating CA 221 lv I ZO 5-8 Gal. ZS - <br /> Waste,Liquid Industrial CA221 Gal. <br /> Old Au...lr Amiaaem.Nan-RCRA H.N. CA 134 Gal. <br /> Wws 4.,d <br /> RO Wws 1omWu,11,ilgmA.N OSNA CAIl Gal- <br /> IWllll Oil wnuminaled vlla l,tl na Fam/F003 _ <br /> Oil&Water,Non-RCRA Hazardous Waste Liquid CA221 00 Gal. <br /> Waste Solids and Sludges Gal. _ <br /> Wash Out Each <br /> Drained Used Oil Filters Drum J �' <br /> Non-RCRA Hamrdous Waste Solids(oily debris) CA223 Drum �7 <br /> Empty Drums Drum <br /> Transportation Hrv' <br /> Non Hazardous Water Gal. <br /> TES7�CIor D Tech 4000 pm ❑ Clor D Tech 1000 Pass ❑FailWEndRet.m <br /> Pass ❑Fail <br /> Field Service Work Description. Total Charges <br /> Other: <br /> Other: <br /> Vacuum Services Time 1 Z /L <br /> Out of Yard On Site Off Site Off Load Stan o Yar <br /> TSDF Consolidated Manifest <br /> ,�5,r� ve reen Oil.Inc. Evergreen Env.Svc.. Evergreen Env.Svc. ❑ AJS Filter ❑ <br /> tN 6880 Smith Ave. ❑ Road 30B ❑ 4193 N.Valentine 15131 Clark Ave- <br /> Newark.CA 94560 Davis.CA 95926 Fresno,CA 93711 Industry,CA 91745 <br /> CAD980887418 CAD982440874 CAD982446882 CAD000097432 <br /> ❑ Evergreen Env.Svc. ❑ Evergreen Env.Svc. ❑ CFR ❑ CFR. ❑ Greenleaf Env.Svc. <br /> 16604S­­­-San Pedr745 A West Beneravol 944 E.Slauson Ave. 33210 Western 3474'foyon Circle <br /> Carson.CA 90746 Santa Maria,CA 93454 Los Angeles,CA 90011 Union City.CA 94587 Valley Springs.CA 95352 <br /> CAD981696420 CAD982446858 CA 1-000110021 CAL000091507 CAL000214411 <br /> Generator certifies that it has established a program to reduce the volume or <br /> Source: IgCollection Station ❑ Government quantity&toxicity ofthe hazardous waste to the degree determined by <br /> ❑ Marine ❑ Agricultural ❑ Industrial generator to be economically practicable. <br /> 1 hereby certify that I have read and have the authority to <br /> bind the above listed enerator to the terms on the reverse <br /> tain Sample I# �� G side of this f0 <br /> o <br /> D er Signature Print Name Route I Cate G nerator rgnature Print Name Date �i <br />