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1 <br />WORK ORDER/SERVICE AGREEMENT <br />Evergreen Environmental Services <br />dedicated to the protection of the environment NO 121366 <br />To schedule ar�pickup, call Send payment to: Sales Order # <br />800-972-5284 Evergreen Oil, Inc. <br />6880 Smith Ave., Newark, CA EPA# CAD982413262 Dept. 2457 <br />16540 S. San Pedro -St., Carson, CA EPA# CAD982413262 Los Angeles, CA 90084-2457 Date: V Z <br />CF.NFRATOR/1011 I.O('ATYON RH.I.ING INFORMATION <br />NA /[ <br />NAME <br />MANIFEST QUANTITY UNITS <br />NUMBER <br />CASH ❑ CHECK ❑ <br />T�✓1 <br />Used oil, Non-RCRA Hazardous Lubricating, <br />CA221 <br /># <br />ADDRESS s• <br />ADDRESS <br />Waste, Liquid Industrial <br />CUSTOMER CODE NO. <br />t. G..j� <br />CAD000097432 <br />❑Evergreen Env. Svc <br />Used Automotive Antifreeze; Non-RCRA Ha—dous <br />Waste Liquid + . <br />ClT STATE ZIP CO. <br />CITY <br />STATE ZIP Co. <br />PO # <br />RQ Wam Combu.4ible Liquid, N.O.S. NA <br />1993 m Oil contaminated .with -halo ens 1 <br />CA221 <br />F001/F002 <br />Gal. <br />R t n sample6 3 <br />PHONE NO. <br />PHONE NO. <br />CA221 <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />Waste Solids and Sludges <br />Gal. <br />PRODUCT <br />WASTE <br />CODE <br />MANIFEST QUANTITY UNITS <br />NUMBER <br />PRICE <br />AMOUNT <br />Used oil, Non-RCRA Hazardous Lubricating, <br />CA221 <br />Gal.: <br />.. <br />Davis, CA 95926 Fresno, CA 93711 <br />Waste, Liquid Industrial <br />CA221 <br />Gal. <br />CAD000097432 <br />❑Evergreen Env. Svc <br />Used Automotive Antifreeze; Non-RCRA Ha—dous <br />Waste Liquid + . <br />CA134 <br />.. <br />Gal. <br />_.... .. 745 A West Betteravia. .944-E.=Slauson.Ave. 33210 Western -,- 3474 Toyon Circle <br />Santa Maria, CA 93454 Los Angeles, CA 90011 Union City, CA 94587 Valley Springs, CA 95352 <br />CAD982446858 CAL000110021 CAL000091507 CAL000214411 <br />Source: lCollection Station ❑ Government <br />RQ Wam Combu.4ible Liquid, N.O.S. NA <br />1993 m Oil contaminated .with -halo ens 1 <br />CA221 <br />F001/F002 <br />Gal. <br />R t n sample6 3 <br />bind the above listed generator to the terms on the reverse <br />side of this form. <br />Oil & Water, Non-RCRA Hazardous Waste Liquid <br />CA221 <br />Gal <br />Waste Solids and Sludges <br />Gal. <br />Wash Out <br />Bach <br />Drained Used Oil Filters <br />Drum <br />Non-RCRA Hazardous Waste Solids (oily debris) <br />CA223 <br />Drum <br />Empty Drums <br />Drum <br />Transportation <br />Hrs. <br />Non Hazar us Water <br />Gal. <br />TEST: ffclor D Tech 4000-t*" ppm ❑ Clor D Tech 1000 <br />Pass ❑ Fail ❑ Halogen Detector/Fiame Test <br />❑ Pass ❑ it <br />Field Service Work Description: <br />Total Charges <br />Other: <br />Vacuum Servic Time <br />Out of Yaz On Site Off Site <br />Off Load StartOff Load End Return to Yard <br />J ` <br />im <br />TS <br />U Consolidated Manifest <br />Evergreen Oil, Inc. <br />❑ Evergreen Env. Svc. ❑ Evergreen Env. Svc. <br />❑ AJS Filter ❑ <br />6880 Smith Ave. <br />Road 30B 4139 N. Valentine <br />15131 Clark Ave. <br />Newark, CA 94560 <br />Davis, CA 95926 Fresno, CA 93711 <br />Industry, CA 91745 <br />CAD980887418 <br />CAD982446874 CAD982446882 <br />CAD000097432 <br />❑Evergreen Env. Svc <br />❑ Evergreen Env. Svc. ❑ CFR I <br />❑ CFR ❑ Greenleaf Env. Svc. <br />16604.S. -San -Pe o. <br />Carson, CA 907 6 <br />CAD9816964 <br />_.... .. 745 A West Betteravia. .944-E.=Slauson.Ave. 33210 Western -,- 3474 Toyon Circle <br />Santa Maria, CA 93454 Los Angeles, CA 90011 Union City, CA 94587 Valley Springs, CA 95352 <br />CAD982446858 CAL000110021 CAL000091507 CAL000214411 <br />Source: lCollection Station ❑ Government <br />Generator certifies that it has established a program to reduce the volume or <br />quantity & toxicity of the hazardous waste to the degree determined by <br />®Marine ❑ Agricultural ❑ Industrial <br />generator to be economically practicable. <br />I hereby certify that I have read and have the authority to <br />R t n sample6 3 <br />bind the above listed generator to the terms on the reverse <br />side of this form. <br />Driv 1 nature <br />rent Name Route # Date G erato Signature Print Name Dat ��+ <br />