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12/16/03 17:25 NORTPDX FRENCH CAMP 4 2094683433 N0.214 D1l <br /> WORK ORDER/SERVICE AGREEMENT <br /> Evergree Environmental Services <br /> dedica d t4 the prwcVon of the environment """o <br /> W O <br /> To sche;IWe a pickup, call Send payment to: Sales Order# <br /> 804ZA.1072.5284 Everen Oil,Inc. <br /> 6880 Smith Ave.,NowaAt.CA CA0982413262 Dept. 2457 <br /> 15540 S_son PedroSt-,CarsAEPA#CAD98241nu Los Angeles, CA)00$42457 Date:GENLRATOR/JOS I,OON BILLING INFORMATION <br /> N �^� �- NAME CASE❑CHECK❑ <br /> ADDRFSS ADDRESS CUSTOMER CODE NO. <br /> S -lb. <br /> ST TE <br /> E ZTP TP Z CO. CITY STATE fCO, PO It <br /> 4 <br /> IPRONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ED NO. <br /> PRODUCT WASTE MANDIST OUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> Used oil,Nan-RCRA Flazardaus Lubricating CA221 Gal. aE+ <br /> Waste,Liquid ludustrial CA221 Gal, <br /> =7 .Nd taxon &U, CAA��1yy34 Gal, <br /> IR <br /> N <br /> t2 nth l awFnrmwxd<SDs_Nw POUI�F'tJn Gal. <br /> Di1&Water,Nan-RC93 A Hard Waste Liquid CA221 Gal. <br /> Waste Solids and Sludges Gal. <br /> l 'Wash Out Each <br /> Drained Used Oil Filters Drum <br /> Non-RCRA Hnretdous Waste Solid (oily debris) CA223 Drum <br /> (Empty Drums Drum <br /> nr ansgortati firs. <br /> INS H Water Gal. <br /> TESTI Clar D Tech 4000 ❑Cior A Tech 1004 Pass[]Fail ❑ Halogen Detector/Ftama Test ❑Ps ❑Fail 201--lo <br /> flsld Service Work Description: Total dar eS <br /> �j Matte,: <br /> w Othe, / <br /> Vacuum Semces Tum <br /> 0m of On Site Off Site O1P Load Stan Off Load End Return a1d <br /> ' TS Consolidated Manifest <br /> Evergreen Qil,Inc. B Env. Svc. ❑)vagtsan Env.Svc. ❑ AJS Filter ❑ <br /> LaB0 Smith Avc. ❑ It MEL 4139 N.on., 15131 Clark Ave. <br /> Newark,CA 943 D via,CA 95926 Fresno,CA 93711 lnduettryry t A 91745 <br /> CAD989887418 C D982446874 CAD982-,16882 CAM 0097412 <br /> Evwgreea Env.Svc, ❑ E ergmcn Env.Svc. l-1 CFR ❑ CFR n chrenleaf Env,Svc. <br /> Carson, <br /> S.San 7 A West Beumvia hJ 944 E.Slauson Ave. 33210 Western t _J 3474 Toyan Circle <br /> yy Carson CA 9 d6 5 to Maria,CA 93454 Los Angeles,CA 90011 Union CityY,CA 94587 Valle 8- <br /> 8p-t-� CA 95352 <br /> CAD98169 0 C 982446858 CAL000110021 CALA00091507 CAI.DU6214411 <br /> Ganarater wroties tbat it has established a Program to reduce the volume ar <br /> Source: Collecdontation 0 GoNernment quumily&toxicity of the hazardous waste to the de;ree determined by <br /> Ll Marine ❑ ieul.tural ❑Industrial generator to be economically practicable. <br /> I hereby certift that I have read and have the authority to <br /> bind the above limed generator to the terms on the reverse <br /> Ret Sample # side of this form. <br /> )� Dri r <br /> Signature Print Name Route# 15ale enerator°s Signature 11rint Name Date <br /> f <br />