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WORK ORDER/SERVICE AGREEMENT <br />Evergreen Environmental Services o 4 <br />dedicated to the protection" of rise environment <br />Toschedule a pickup, call Send payment to: Sales Order # <br />800-977 2®5204 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: <br />GENE T R/JOB LOCATION BILLING INWORMATION <br />—�— — <br />NAMYli <br />NAME <br />#ASH ❑ CHECK ❑ <br />ADD,S q / ® <br />e[ <br />. _. 7c, 4( <, O <br />ADDRESS <br />CUSTOMER DE NO. <br />i <br />CITY STATE ZIP CO. <br />--- <br />CI'T'Y STATE ZIP CO. <br />PO # <br />CA221 <br />Gal. <br />PHONE NO.Z��/ <br />PHONE NO. <br />PROFILE NO. <br />CUSTOMER EPA ED NO. <br />RQ Wuee Combustible Liquid, N.O.S. NA <br />1 3917 COn wmamineted with heloma) <br />CA227-iJ <br />FWiMC) 2 <br />Gal. <br />PRODUCT <br />WASTE MA .ST CODE NUMBER QUANTITY <br />UNITS PRICE <br />AMOUNT <br />Used ori, Non RCRA Hazardous Lubricating <br />CA221 ® <br />Gal. <br />Waste, Liquid Industrial <br />CA221 <br />Gal. <br />U�1 Automotive Andf"w. Non-RCRA H. dnus <br />Wa 7d <br />CA334 __"_.._r. __..__�- <br />Gal. <br />RQ Wuee Combustible Liquid, N.O.S. NA <br />1 3917 COn wmamineted with heloma) <br />CA227-iJ <br />FWiMC) 2 <br />Gal. <br />Oil & Water, Non-RCRA Hazardous Waste Liquid <br />CA221 <br />Gal. <br />Waste Solids and Sludges <br />Gal. <br />Wash Out <br />Drained Used Oil Filters <br />Brum <br />Nan-RCRA Hazardous Waste Solids (oily debris) <br />CA223 <br />Drum <br />Empty Drurns <br />Drum <br />Transportation <br />Hrs. <br />Non Hazardous Water <br />Gal. <br />TEST:C]or D Tech 4000 ppm ❑ Clor D Tech 1000 Pass ❑ Fail ❑ Halogen Detector/Rame Test ass ❑Fail <br />Field Service Work Description: <br />Total Charges <br />Other: <br />Other: <br />Vacuum Services Time <br />Out of Yard On Site _._..____Off Site <br />— Off Load Start Off Load End <br />Return to Yard <br />TSDF <br />Evergreen Oil, Inc. <br />6880 Smith Ave. <br />Newark, CA 94560 <br />CAD980887418 <br />❑Evergreen Env. Svc. <br />Road 30B <br />Davis, CA 95926 <br />CAD982446874 <br />Consolidated ManirNc <br />Evergreen Env. Svc. AJS Filter / <br />4139 N. Valentine 15131 Clark Ave.LJ <br />�,,�,� <br />Fresno, CA 93711 Industrryy. CA 91745 <br />CAD982446882 CAD000t197432 <br />❑Evergreen Env. Svc.ElEvergreen Env. Svc. ❑ CFR n CFR ❑ Greenleaf Env. Svc. <br />16604 S. San Pedro 745 A West Betteravia 944 E. Slauson Ave, I J 33210 Western 3474 Toyon Circle <br />Carson, CA 90746 Santa Maria, CA 93454 Los Angeles, CA 90011 Union City, CA 94587 Va11cyy Sppanngs, CA 95352 <br />CAD981696420 CAD982446858 CAL.000110021 CALM0091507 CAL(>00214411 <br />Generator certifies that it has established a program to reduce the volume or <br />Source: gColleetion Station L] Government quantity & toxicity of the hazardous waste to the degree determined by <br />❑ Marine U Agricultural ® Industrial generator to be economically practicable. <br />I hereby certify that I have read and have the authority to <br />bind_ thea <br />bove listed generator to the terms on the reverse <br />alit Sample # _..__.____.__ side of this form. <br />6 11 Z3103 m3 <br />D ver Signature Print Name Route # Date Gratorrgnature Print Name Date <br />