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WORK ORDER/SERVICE AGREEMENT <br /> Evergreen Environmental Services N'i`!h'G'ti � . HEAL 1 fi N° 160919 <br /> qtr- ; <br /> / dedicated to the protection of the environment -, !' '1 )-I j�V'C <br /> To schedule arkpickup, call Send payment t®3 NOV 13 pM 2; -Sales Order <br /> 800-972-5284 Evergreen Oil, Inc. V� <br /> 6880 Smith Ave.,Newark,CA EPA#CAD982413262 Dept. 2457 6 <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 Los Angeles, CA 90084-2457 Date: <br /> GENERATOWJOP LOCATION BILLING INFORMATION <br /> NA= NAME CASH❑ CHECK❑ <br /> # <br /> ADDR19SS ADDRESS CUSTJJMER CODE NO. <br /> 1 Z 2v Sf" , I <br /> Cyry STATE ZIP CO. CITY STATE ZIP CO. PO# <br /> CD' <br /> PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. <br /> ( ) I ICA COr?� <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> C Used oil,Non-RCRA Hazardous Lubricating CA221 C� Gal. 75-- <br /> Waste, <br /> S:acsWaste,Liquid Industrial CA221 Gal. <br /> Used Aummmive Antiftme,Non•RCRA Hazardous <br /> waste Li uid CA134 Gal. <br /> RQ Wute Combustible Liquid,N.O.S.NA CA221 Gal. <br /> 1993 fIl Oil contaminated with halo ens F001/F002 <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 Drum <br /> Transportation Hrs. <br /> Non Hazard <br /> s Water ^^�� Gal. <br /> TEST: Clor D Tech 4000�3z��ppm ❑Clor D Tech 1000 FXass❑Fail ❑ Halogen Detector/Flame Test ass ❑Fail <br /> Field Service Work Description: Total Clmt-Les <br /> Other: <br /> Other: <br /> Vacuum S ices Time <br /> Out of azd On Site Off Site Off Load Start Off Load End Return to Y 5 <br /> TS Consolidated Manifest <br /> Evergreen Oil,Inc. ❑ Evergreen Env.Svc. ❑ Evergreen Env.Svc. ❑ AJS Filter ❑ <br /> 6880 Smith Ave. Road 30B 4139 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. 1:1CFR 1:1CFR ❑ Greenleaf Env.Svc. <br /> 16604 S.San Ped 745 A West Betteravia 944 E.Slauson Ave. 33210 Western 3474 Toyon Circle <br /> Carson,CA 907 Santa Maria,CA 93454 Los Angeles,CA 90011 Union City,CA 94587 Valle <br /> yy Spprings,CA 95352 <br /> CAD9816964 CAD982446858 CAL000110021 CALOOM91507 CAL000214411 <br /> Generator certifies that it has established a program to reduce the volume or <br /> Source: YCollection 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 the terms on the reverse <br /> R n sample # 57 C le —_— side of this form. <br /> D ' r Signature Print Name Route # bate Generator's Signature Print : ' 111C Date <br />