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2011-Feb-11 02:10 PM DSW AG 209-339-8867 33/42 <br /> A/, WORK ORDER/SERVICE AGREEMENT <br /> Evergreen En tronmental Services o <br /> _. dedirnred fn rirc Protection of the envbonrnent N- 14W4 <br /> To schedule a ickup. call fiend payment tu: Sales Order <br /> 800-972 5284 Evergreen oil, Inc. <br /> • 6880 Smith Ava.,Newark,CA EPAJ CA 982413262 Dept. 2457 !� <br /> 10340 S.San Pedro St.,Carson,CA EPA*CAD982413262 Los Angeles.CA 90084-2457 Date:5.2 -61 t> <br /> `I GENERATOR/JOB LOCATION BILLING INFORMATION <br /> o NAME _ NAME CASH (AMCK <br /> l <br /> ADDRESS ADDRESS CUSTOMER CODE 1 <br /> ,' - <br /> CITY STATE ZIP CO. CITY STATE ZIP CO. PO <br /> 1 <br /> PHONE NO. /,.>D NO. PROFILE NO. CUSTOMER ZPA IO. <br /> NO. <br /> (- ( ) L Z)�_,a ' Z_/..a <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS' PRICF. AMOUNT <br /> CODE NUMBER <br /> Used oil.Non-RCRA Hazardous LubAenting CA321 <br /> Waste,Liquid Indu trial CA221 Gal. - <br /> U.ed Aatu,n„dw AnONVA Not!-11 RA Flafanl,m+id CA 134 Gail. - . <br /> ap WRee(5,mh„Ylhl�E.YYuId.N.u3.NA f.'n2]I Qal <br /> Mir Ih haG.ms FiNn n•�n2 - 1 <br /> oil R Water.Non-RCRA Hazardous Wuste .iyuid CA221 Gail. <br /> Waste Solids and Sludges Gad, ti <br /> Wash Out Each <br /> Drained Used Oil Pilters Drum <br /> Non-RCRA Hazardous Waste Solids(oily de, ls) CA223 Dmm. <br /> Empty Druhu +'i Drumi- <br /> Transportation Hp. •. <br /> Non Hazard s Water (}al. ,•r ;5, `'v <br /> TEST:121clar D Tech 4MID_ppm Clor D Tech IUW Paas Q Fail ❑ Halogen Detector/Flitme Teat [A`Sj: ❑:Fail <br /> Field Service Work Description: Total Char es , <br /> ,. <br /> Other: <br /> Other- <br /> Vacuum <br /> therVacuum Services Time <br /> Out of On Site-OftSite Off Load Stan Oft Load End etum to Yard <br /> TS I I Consolidated Manifest <br /> %88r;rccn Oil.Inc. Evugn on .nv,Svc. E] Evergreen Env.Svc, AJS Filter <br /> Smith Ave. Read 300 4139 N.Valentino 1 15131 Chuk Ave. <br /> Ncwurk,CA 945611 Davis.CA 5926 Fresno,CA 93711Industtryry CA 91745 <br /> CAD98U887418 CAD9R? i37! cAD942A461i32 CAD000097432 <br /> ❑ Everrreen Env.Svc. ❑ Evergreen inv.Svc. ❑ CFR CFR ❑ Greenleaf Env.Svc. <br /> 16604 S.Sun Pc: , 745 A WuA Botaurtvla 944 E.Sluuson Ave. 332I0 Western 3474 Teyon Circle <br /> Causun.CA 90 6 Santa Marip,CA 93454 Los Angeles,CA 90011 Union Cityy,CA 94587 Valleyy Sp n'ngs,CA 93352 <br /> CAD98169 CAD982446855 CALM0110021 CAL000091507 CAL00021441I <br /> Generator certifies that It has established a program to reduce the volaiite'or - <br /> EO <br /> urCe: Collection Statial� Z1 Government quantity&toxicity of the hazardous waste to the degree determined by <br /> E] Marine C3A ricvltural Industrial Seaentor io be economically practleabie. <br /> I hereby_cerdfy that I have read and have the authority to.. <br /> bind the above listed Generator W the terms on the reverse <br /> Retain sample # ��—T - ( lido of this form. <br /> Driver Signature print Name Route# ! Date Ge6eratortsMg—nature Print Name Date <br />