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WORK ORDER/SERVICEN AGREEMENT <br /> 63022 <br /> Evergreen Environmental Services <br /> dedicated to the protection of the environment <br /> To schedule a pickup,call Send payment to: Sales Order H t5`7 3 <br /> 800-972-5284 Evergreen <br /> 68Smith Ave.,Newark. CA EPA#CAD982413262 P.O.Ras 19065 <br /> 80 l Z$-GZ <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982473262 San lose.CA 95161-9061 Dale' <br /> GENERATOR/JOB LOCATION BILLING INFORMATION <br /> NAME CASH ❑CHECK❑ <br /> a� 3L1 �s1 1$ <br /> ADDRESS ADDRESS CUSTOM ER CODE NO. <br /> -Z <br /> CITY STATE ZIP CO. CITY STATE ZIP CO. PO <br /> 4D <br /> 71 NO. PHONE NO. PROFILE NO. CUS'j'(DT�PA ID NO. <br /> jRCRA <br /> DUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> Used oil.Non- ivardnus Lubricating CA 221 q 7 7 Q O Gal.Wasste.liquiIndustrial CA221 Gal. <br /> I mit Amimnm.rum-M RA llvar4-,,, CA134 Gal. <br /> rRI)M. r,.nn, .1.ns nA c^'--''-I Gal. <br /> n M1 IVlmensl FWIIFW2 <br /> Oil&Warcr.Nnn-RC'RA Hwardous Waste Liquid CA221 J - �'/ GD Gal. <br /> 'Aamc Solids and Sludges Gal, <br /> W'a1h Out Each <br /> Drained Used Oil Filters Drum <br /> Non-RCRA Hazardou Waste Solids(oily debris) CA223 Drum <br /> Drum <br /> Emptv Drums <br /> H <br /> l'ransportation <br /> Non Hvardous Water <br /> Gal. <br /> .I FS"r:PClor D Tech 4000pm ❑ Clor D Tech 1000 gPass❑Fail ❑ Halogen Detector/Flame Test ass ❑Fail ..� <br /> Field Service Work Description: Total Charges <br /> Other. <br /> Other: <br /> Vacuum Services Timc S 7s'. <br /> Om ol'Yard On Site OBSitc Off load Stan Of Load End Retum o Yard <br /> TSDF M Consolidated Manifest <br /> f Evergreen Oil.Inc. ❑ Evergreen Env.Svc. ❑ Evergreen Env.Svc. ❑ AJS Filter <br /> !21 6880 Smith Ave. Road 30B 4193 N.Valentine 15131 Clark Ave.. <br /> El <br /> Newark.CA 94560 Davis.CA 95926 Fresno,CA 93711 Industry.CA 91745 <br /> CAD980897418 CAD982446874 CAD982446882 CAD000097432 <br /> Evergreen linv.Svc Evergreen Env.Svc. CFR CFR. Greenleaf Env.Svc. <br /> 1660.1 S.San Pedro 745A West Beneravia 944 E.Slauson Ave. 33210 Western 3474'royon Circle <br /> Carson.CA 90746 Santa Maria.CA 93454 Los Angeles.CA 90011 Udion City.CA 94587 Vallev Springs.CA 95352 <br /> CAD981696420 CAD982446858 CAL000110021 CALOOOO91507 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 lathe degree determined h} <br /> (3 Marine El Agricultural ®'Industrial generator to he economically practicable. <br /> 1 hereby certify that 1 have read and have the authority to <br /> bind the above listed.generator to the terms on the reverse <br /> tain sample # side of this form. <br /> iver Signature Print Name Route # Date rTeratorS Signat a Print Name Date <br />