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12/16/03 17:25 NORTP` FRENCH CAMP 4 2094683433 NO.214 P09 <br /> 1 ' <br /> WORK ORDER/SER TCE AGREEMENT <br /> Evergreen nvironmental Services o <br /> dcdicared iD Me prorecrion of rhe envdrownew 125554 <br /> To schedua a pickup,, call Send payment to: Sales Order�# <br /> p�0;p 72-5284 Evergreen oil, Inc. <br /> 6880 Smith Ave.,Newark CA09924t3262 Dept. 2457 u Z� <br /> 10540 S.San Padro St_,Cwwr,C EPA#CA0982413262 Los Angeles,CA 90084-2457 Date: �I <br /> GENERATOR/JOB LOCA ON BILLING JNFORIVIATION <br /> N NAME CASE/❑ CHECK❑ <br /> 0 <br /> ADDRESS ADDRESS CUSTOMER CODE NO. <br /> Sa. I H7 <br /> CITY STA ZrP CO. CITY STATE ZIP CO. PO# <br /> ONE NO. PHONE NO. PROME NO. CUSTOMER EPA ID NO. <br /> i <br /> WASTE MANIFEST <br /> PRODUCr CODE NUMBER QUANTITY UNITS PRICE AMOUNT <br /> Ustd oil,Non-PCRA Hazardous Lubricating CA221 f7 Gal. <br /> Waste,Liquid Industrial CA221 Gal, <br /> U-1 Au —Ua n,ror-zr,N,o-RCRA H=ft CA134 Gal. <br /> RQwua toMbsafbY 1.10id.N.O.S.NA CA221 <br /> 09�In 011--ti m yah h.i FOO 1/FM Gal. <br /> Oil&r Water,N013•RCFA Hazardous aste Liquid CA221 Gal. <br /> Waste Solids and Sludges Gal. <br /> Wash out Each <br /> Drained Used Oil Fltnrs Drum <br /> Nqu-RCRA Hazardous Waste Solids( ily debris) CA223 Dnim <br /> Empty Drums Arum <br /> Ttanspottation <br /> HrS. <br /> Non H Water <br /> TEST: Oor D Tech ❑Clor D Tech OOF P4ss ❑Fail ❑ Halogen Detector/Flame Test Pass ❑Fail Dcx-D <br /> Field Service Worst Description:Other.Other.YJCuum cns Time <br /> Ott of and On Site Off Site Off Load Start Off Load Erd Fw to Yard <br /> TS Consolidated Manifest <br /> YFvFgrftn Oil,Tnc. ❑ E cn Env.Svc. ❑ Evergreen Env,Svc. ❑ AJS Filter ❑68Smith Ave. Roar 30B 4139 N.Valentine 15131 Clark Ave. <br /> Newark,CA 94560 Davi,CA 95926 Fresno,CA 93711 Industry,CA 91745 <br /> CAD98D887418 CA 82446874 CAD982446992 CAD000097432 <br /> ❑ Evergreen Y�46 <br /> ❑ Lvmireen Env.Svc. U CFR ❑ CM ❑ Greenleaf F-nv-Svc, <br /> 16604 S.S745 A West BetteraviQ 944 E Slaason Ave. 33210 Western 3474 Toyon Circle <br /> tars<m.CA Santa Maria,CA 93454 Lw Angeles,C4 90011 Union Ciry,CA 94587 Valley Springs,CA 95352 <br /> CAD991 C 82446858 CAI.000I to021 CAL000091507 CAL00021441 l <br /> Generator certifies that it has established a program to reduce the volume or <br /> Source: Collection St tion 0 Government quantity&toxicity of the hazardous wa6tc to the degree determined by <br /> ❑Marine ❑A icultural D Industrial generator to be economically praclicablc. <br /> I here!a eer_dfy_Shat I have read and have the aathoi iy to <br /> bind the above listed generator to the terms on the reverse <br /> to sample # side of this form. <br /> DI Signature Print ame Route# jbatet en rotor's Signature Print Name Date <br />