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WORK ORDER/SERVICE AGREEMENT <br />It. <br />Evergreen Environmental Services NO 152939 <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 Dept. 2457 '::4 <br />16540 S. San Pedro St., Carson, CA EPA# CAD982413262 Los Angeles, CA 90084-2457 Date: <br />GENERATOR/JOB LOCATION BILLING INFORMATION <br />N E Ir <br />WASTE <br />CODE <br />NAME <br />AMOUNT <br />CASH ❑ CHECK ❑ <br />CA221 <br />LZJ0570473 APO Gal. Q� w <br />Waste, Liquid Industrial <br />CA221 <br />AWkESS <br />ADDRESS <br />CA134 <br />CUS O R CODE NO. <br />�'5 C. <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993 111 Oil contaminated with halo ens <br />CA221 <br />F001/F002 <br />Gal. <br />Z <br />CITY STATE <br />CO. <br />CITY <br />STATE ZIP CO. <br />PO # <br />gZIP <br />O <br />Wash Out <br />PHONE NO. <br />PHONE NO. <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />-t> <br />CA223 <br />( ) <br />Empty Drums <br />PRODUCT <br />WASTE <br />CODE <br />MANIFEST QUANTITY UNITS PRICE <br />NUMBER <br />AMOUNT <br />Used oil, Non-RCRA Hazardous Lubricating <br />CA221 <br />LZJ0570473 APO Gal. Q� w <br />Waste, Liquid Industrial <br />CA221 <br />Gal. <br />Used Automotive Antifueu, Non-RCRA Hazardous <br />Waste Li uid <br />CA134 <br />Gal. <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993 111 Oil contaminated with halo ens <br />CA221 <br />F001/F002 <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 />Each <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 />Transportatio <br />Hrs. <br />Non Hazaz us Water""__ <br />Gal. <br />TEST: Clor D Tech 4002--Q—ppm ❑ Clor D Tech 1000 <br />Pass E]Fail <br />Pass ❑ Fail ❑ Halogen Detector/Flame TestO <br />?p <br />Field Service Work Description: <br />Total Charges <br />Other: <br />Other: <br />Vacuum S ices Time <br />Out of rd On Site --Off Site <br />Off Load Start Off Load End eturn to Yard <br />TS Consolidated Manife <br />Evergreen Oil, Inc. ❑ Evergreen Env. Svc.❑ Evergreen Env. Svc. �— I AJS Filter <br />6880 Smith Ave. Road 30B 4139 N. Valentine D 15131 Clark Ave. <br />Newark, CA 94560 Davis, CA 95926 Fresno, CA 93711 Industry, CA 91745 <br />CAD980887418 CAD982446874 CAD982446882 CAD000097432 <br />10 <br />❑Evergreen Env. vc. ❑ Evergreen Env. Svc. ❑ CFR ❑ CFR ❑ Greenle nv. Svc. <br />16604 S. San dro 745 A West Betteravia 944 E. Slauson Ave. 33210 Western 3474 Toyon <br />Carson, CA 746 Santa Maria, CA 93454 Los Angeles, CA 90011 Union City, CA 94587 Valley Springs, CA t <br />CAD98169 20 CAD982446858 CAL0005110021 CAL000091507 CAL000214411 <br />Generator certifies that it has established a program to reduce the volume or <br />Source: A Collection Station ❑ Government quantity & toxicity of the hazardous waste to the degree determined by <br />❑ Marine LlAgricultural ❑ 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 />ain sample # -7 C_ 3 side of this form. <br />river Signature Print Name Route # ate ene ator's Signature Print Name Date <br />