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WORK ORDER/SERVICE AGREEMENT <br /> A NVEvergreen Environmental Services A NO- 194564 <br /> dedicated to the protection of the environment <br /> r To schedule a pickup, call Send payment to: Sales Order # <br /> 800-972-5284 Evergreen Oil, Inc. <br /> 6880 Smith Ave.,Newark,CA EPA#CAD982413262 P.O. BOX 678252 <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 Dallas,TX 75267-8252 Date: <br /> GENERATOR/JOB LOCATION BILLING INFORMATION <br /> N>A < NAME CASHE] CHECK❑ <br /> ADDRESSADDRESS CUSTOMER CODE NO. <br /> 4170V <br /> CITY STATE ZIP CO. CITY STATE ZIP Co. PO# <br /> .4;;6u9e6/y_*- Jlr- <br /> PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. <br /> 0131� <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER -1 <br /> Used oil,Non-RCRA Hazardous Lubricating CA221 Gal. 4/57%Z1> <br /> Waste,Liquid Industrial CA221 Gal. <br /> Used Automotive Antifreeze,Non-RCRA Hazardous CA 134 Gal. <br /> Waste Liquid --—CA22—I <br /> RQ Waste Combustible Liquid,N.O.S.NA Gal. <br /> 1993 In(Oil contaminated with halogens) F00l/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 W ste Solids(oily debris} CA223 Drum <br /> Empty Drums Drum <br /> Transportation Hrs. - <br /> Non Hazr44 Water Gal. I <br /> TEST:?rClor D Tech 4000ppm ❑Clor D Tech 1000 <br /> Pass D Fail F] Halogen Detector/Flame Test 0 Pass E]Fail ZV,---YQ <br /> - <br /> Field Service Work Description: Total Charges <br /> Other: <br /> Other: <br /> Vacuum Services Time ems, 0 <br /> Out of Yard-On Site-off Site-Off Load Start-Off Load End-Return to Yard <br /> TSDF D Consolidated Manifest <br /> El Evergreen Env.Svc. AJS Filter ❑ <br /> Road 30B 4139 N.Valentine 15131 Clark Ave. <br /> Evergreen Oil,Inc. Evergreen Env.Svc. <br /> 6880 Smith Ave. F] I El <br /> Newark,CA 94560 Davis,CA 95926 Fresno,CA 93711 Industry,CA 91745 <br /> CAD980887418 CAD982446874 CAD982446882 CAD000097432 <br /> ❑ E Evergreen Env.Svc. F7 CFR 0 CFR El Greenleaf Env.Svc. <br /> 16604 S.San Pedro <br /> vergreen Env.Svc. F❑ <br /> 745 A West Betteravia " 944 E.Slauson Ave. 33210 Western 3474 Toyon Circle <br /> Carson,CA 90746 Santa Maria,CA 93454 Los Angeles,CA 90011 Union City,CA 94587 Valley Springs,CA 95352 <br /> CAD981696420 CAD982446858 CAL0001 10021 CAL000091507 CAL000214411 <br /> Generator certifies that it has established a program to reduce the volume or <br /> Source: LICollection Station U Government quantity&toxicity of the hazardous waste to the degree determined by <br /> Lj Marine L) Agricultural L) Industrial generator to be economically practicable. <br /> I hereby certify that I have read and have the authorityto <br /> bind the above listed generator to the terms on the reverse <br /> tain sample # side of this form. <br /> S <br /> ri r Signature int Name Route# Date ef--nerator's Signature Print Name Date <br />