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2011-Feb-11 0210 PM DSW AG 209-3.3a-8867 37/42 <br /> WORK ORDER/SERVICE AGREEMENT <br /> Evergreen E vironmental Services NQ 102391 <br /> drdicurcd to rc/rrnrrctinn of rlrr errrimrrnrent <br /> To schedule pickup, call `clad lwt nu nl f:.: Sales Order# "*7VJBY7 <br /> 800-97 -5284 Evergreen 011, Inc. <br /> 6880 Smith Ave.,Newark,CA EPA# A0982413262 Dept. 2457 <br /> 18640 S.San Pedro at.,Carson,GA PAW CA0962413262 Los Angeles, CA 90034-2457 Date: NZ7Ia2- <br /> GENERATOR/ OB LOCATI N BILLING INFORMATION <br /> I <br /> E NAME CASH E CHECK <br /> S # <br /> ADDRESS ADDRESS CU OMER CODE NO, <br /> CFY % STATF, o CO. CITY STATE ZIP CO. PO# <br /> PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. <br /> a� —Lrli ( ) I C,_1 *4D 4M 3210 <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> Used oil,Non-RCRA Hazardous Lubricating CA221 J s'/j Gal. x <br /> Waste.Liquid In ustrial CA221 Gal. <br /> u�a AVI 11vt Aauf me No RCRA uauvdnm, CA 134 Gel. <br /> Wute Li old <br /> RC­ 1,Ll,yWa N.O.S.NA CA2a Gai• <br /> 3 lil 1011 rnn,amin�eed,wm nal,,enx FSq IlFT10: <br /> 011&Water.Nan-RCRA Hazardous Wag Li aid CA221 Gal. <br /> Waste Sollda and Sludges Gal. <br /> Wash Out Each <br /> Drained Used 011 Filters Drum <br /> Von-RCRA Hazardous WeAtc Solids(oily debris) CA223 Drum <br /> Empty Drums Drum <br /> Transportation Hrs, <br /> Non Hazardous Water Gal. <br /> TEST:ErClor D Tech 4004&.—ppm Clor D Tech 1000armA❑Fail ❑ halogen Deteetor/Mame Test ❑Pass Pail ,�J9 <br /> Field Service Work Description: I •;: I ( f1: tl l <br /> Other. <br /> Other. <br /> Vacuum SarvicoN Titre LL`` <br /> Out of Yard On Sitc ff Site Off Load Sian Off Load End Return to <br /> TSDF W Consolidated Manifest <br /> 11;7rHvergreen Oil,Inc. ❑ F.vergredn Env.Svc. f7 Evergreen Env.Svc. AJS titer n <br /> 6660 Smirh Avc. Rou 3013 4139 N.Valentlno 13131 Clark Ave. u <br /> Newark.CA 94560 Davis.CAA 95926 Fresno,CA 93711 Indus��77rr CA 91749 <br /> CAD9R099741R CAD9112446874 CAD982446392 CAD000097432 <br /> ❑ Evergreen Env.Svc. 1:1 Evergreen Rnv.Svc, ❑ CFR CPR Greenleaf Env.Svc. <br /> 16604 S,San Pedro 745 r Wcxl Bettcnvta 944 E.Slauson Ave. 33210 Western 3474 To an Circle <br /> Carsnn,CA 90746 Santa M 'a,CA 93454 Los Angeles,CA 90011 Union Cityy,CA 445$7 Vail SyPPringsi CA 9535: <br /> CAD991696420 CAD9B2 46958 CAL000110021 CAL00009IS07 CA ;A144 <br /> Generator canifles that It has established a program to reduce the volume or <br /> Source: 2D Collection Statin C]Government qunmity&toxicity of the hazardous waste to the degree determined by <br /> ❑ Marine ❑ /� cultural Z) Industrial generator to be economically prneticable. <br /> I hereby certify that I have read and have the authority to <br /> S �` bind the above listed generator to the terms on the reverse <br /> Re n sample # aide of this form. <br /> 7 , 6 cf� - <br /> Dri r Signature Print Narne Route# Dfate Generator's Signature Print Name Date <br />