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ABill of Lading/Invoice <br /> Evergreen Environmental Services 794653 <br /> dedicated to the protection of the environment <br /> To schedule a pickup, call Send payment to: Sales Order# <br /> 800-972-5284 Evergreen <br /> 6880 Smith Ave.,Newark, CA EPA#CAD982413262 P.O.Box 49065 - <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 San Jose,CA 95161-9065 <br /> Date <br /> JOB LOCATION BILLING INFORMATION <br /> NAME NAME CASH ❑ CHECK[] <br /> /2 /f / # <br /> ADUREPS ADDRESS <br /> CUSTOMER CODE NO. <br /> /964S ,Q�, Q� <br /> CITY STATE ZIP CO CITY STATE ZIP CO PO <br /> PHONE NO. PHONE�NO. i PROFE.E NO. CUSTOMER EPA m NO. <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER (For Time Of Service Only) <br /> Used oil,Non-RCPA Hazardous Lubricating CA 221 Gal <br /> Waste,Liquid Industrial CA 221 GatUsed Automotive Anti6eece,Non-RCRA Hazardous CA 134 Gal <br /> Waste,Liquid <br /> RQ Waste Combustible Liquid,N.O.S.NA CA 221 GM <br /> 1993 M(Oil contaminated with halogens) Ia IRM <br /> ()it&Water,Non-RCPA Hazardous Wat; Liquid CA221 % Gal <br /> Waste Solids and Sludges Gid <br /> Washout <br /> IhEach <br /> ahted Used Oil Filters fJegl Drum <br /> tis <br /> Non-RCRA Hazardous Waste Solids(oily debris) CA 223 / u Dimon Drums air <br /> Drum <br /> Transportation His. <br /> Other. <br /> Littler: <br /> Other: <br /> Other: <br /> Other: <br /> Other: <br /> Other: <br /> Other: <br /> TAT PASS❑ FAIL❑ PPM Test <br /> ❑Collection Station ❑Agricuhura!Source TOTAL <br /> [I Government Source ❑Industrial Source <br /> ❑Marine Source <br /> CHARGES 350,000 <br /> "YOU WILL ALSO RECEIVE A COMPUTER Accounting Office 949-757-7770 <br /> GENERATED INVOICE AND/OR <br /> STATEMENT FROM OUR ACCOUNTING OFFICE. I hereby certify that all information in this and all attached documents <br /> PAYMENT AT TIME OF SERVICE WILL contains true and accurate descriptions of the waste.All relevant infamtation regard- <br /> ALSO BE NOTED ON INVOICE". ing(mown or suspected hazards associated with the waste has been disclosed. <br /> TSDF: Evergreen Oil, Inc. I also acknowledge that I have read and agree to the terms on the reverse side <br /> of this form. <br /> 6880 Smith Avenue Pursuant to Tide 22,Section 66264.12,Evergreen Oil,Inc,Evergreen <br /> Newark, CA 94560 Environmental Services,has the appropriate permits for and will accept <br /> the wastes manifested to Evergreen facilities so long as it mats the <br /> EPA#CAD980887418 approved acceptance criteria. <br />