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WORK ORDER/SERVICE AGREEMENT <br /> Evergreen Environmental Services NO- 187564 <br /> dedicated to the protection of the environment <br /> 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 /> C) <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 Dallas, TX 75267-9252 Date: <br /> /W <br /> GENERATOR/JOB LOCATION BILLING INFORMATION <br /> N>W# -? NAME 41_A CASHE] CHECKE] <br /> -7 41-r # <br /> ADDRESSADDRESS CUSTO ER CODE NO. <br /> e-1-7 (>q C'1, <br /> CIT)f STATE ZIP CO. CITY STATE ZIP Co. PO# <br /> C4 7rZ/,y- <br /> PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. <br /> Z.=J,(4hot -- I <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> Used oil,Non-RCRA Hazardous Lubricating CA221 Gal. <br /> Waste,Liquid Industrial CA221 Gal. <br /> Used Automotive Antifreeze,Non-RCRA Hazardous CA134 Gal. <br /> Waste Liquid <br /> RQ Waste Combustible Liquid,N.0 ,IA CA221 <br /> contaminated in(Oilcontaminated with halo 01/F002 Gal. <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 Waste Solids(oily debris) CA223 Drum <br /> Empty Drums Drum <br /> Transportation Hrs. <br /> Non Hazarz Water Gal, <br /> TEST:Xclor D Tech 4000-A2 U—t ppm E Clor D Tech 1000 PassE]Fail E] Halogen Detector/Flame,Test FIP/ E] Fail ?P,..PC> <br /> Field Service Work Description: Total Charges <br /> Other: <br /> Other: <br /> Vacuum SeAs Time <br /> Out of Y,/d— On Site—Off Site—Off Load Start Off Load End Return to <br /> TS Evergreen Oil,Inc. F ❑ Consolidated Manifest <br /> Evergreen Env.Svc. Evergreen Env.Svc. ❑ AJS Filter ❑ <br /> 6880 Smith Ave. Road 30B 4139 N.Valentine 1:1 15131 Clark Ave. <br /> Newark,CA 94560 Davis,CA 95926 Fresno,CA 93711 Industry,CA 91745 <br /> CAD98088741 8 CAD982446874 CAD982446882 CAD000097432 <br /> ❑ Evergreen Env.S ❑ Evergreen Env.Svc. ❑ CFR CFR ❑ Greenleaf Env.Svc. <br /> 16604 S.San P&Vc 1 745 A West Betteravia 944 E.Slauson Ave. 1:1 33210 Western 3474 Toyon Circle <br /> Carson,CA 90Y6 Santa Maria,CA 93454 Los Angeles,CA 90011 Union City,CA 94587 Valley Springs,CA 95352 <br /> CAD981696Y-O CAD982446858 CAL0001 10021 CAL000091507 CAL000214411 <br /> Generator certifies that it has established a program to reduce the volume or <br /> Source: (9 Collection Station J Government quantity&toxicity of the hazardous waste to the degree determined by <br /> ❑Marine j Agricultural Ll Industrial generator to be economically practicable. <br /> I hereby certify that I have read and have the authority to <br /> bind the above listed generator to the terms on the reverse <br /> R t n sample # C_ �f side of this form. <br /> Dfi Signature f Print Name Route# t Date Ge era s Si��iatu Print Name Date <br />