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Bill of Lading <br /> Evergreen Environmental Services <br /> 735040 <br /> / dedicated to the protection of the environment <br /> To schedule a pickup, call Send payment to: Sales Order# 96-3 T7 2 3 <br /> 800-972-5284 Evergreen <br /> 6880 Snft Ave.,Newark, CA EPA#CADM413262 P.O.Box 49065 <br /> 16540 S.San Pedro SL,Carson,CA CEPA#CAD982413262 San Jose,CA 95161-9065. Date /Z_2, -' f9 <br /> JOB LOCATION - BILLING INFORMATION <br /> NAME NAME CASH ❑ CHECK[] <br /> Cv # <br /> ADDRESS -. - ADDRESS ". _ _ CUSTOMER CODE NO. <br /> CITY STATE ZIP CO CITY STATE ZIP CO PO# <br /> 7 C S� J:oy- '952W <br /> PHONE NO. .. -PHONE NO. PROFILE NO. CUSTOMER EPA m NO. <br /> Z09 94a - SSS b 17Ut1 55! <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER (For Time Of Service Only) <br /> Used oil,Non-RCRA Hazardous Lubricating CA 221 Gal <br /> Waste,Liquid Industrial CA 221 Gal <br /> Used Automotive Antifreeze,Non-RCRA Hazardous CA 134 Cal <br /> Waste,Liquid <br /> RQ Waste Combustible Liquid,N.O.S.NA CA 221 - Gal <br /> 1993ID(Oil contandnitud with halogens) 1091802 <br /> Oil&Water,Nen-RCRA Hazardous Waste,liquid CA221 Z Gal <br /> Waste Solids and Sludges Gal <br /> Wash- ut Each <br /> Drained Used Od Filters Drum <br /> Non-RCRA Hazardous Waste Solids(oily debris) CA 223 Drum <br /> Ply Drums Drum <br /> Dow. <br /> Other: <br /> Other: <br /> Other: <br /> Other. <br /> Other: <br /> TEST PASS❑ FAIL❑ PPM Teat <br /> ❑Collection Station ❑Agricvldnal Source . <br /> ❑Government Source ❑Indus"Source TOTAL <br /> ❑Marine Source <br /> CHARGES <br /> "THIS IS NOT AN INVOICE;YOU WELL Accounting Office 949457-7770 <br /> RECEIVE AN INVOICE FROM OUR <br /> ACCOUNTING DEPT. PAYMENT AT TIME OF I hereby citify that all infomsdon in this and all attached documents <br /> SERVICE WILL ALSO BE NOTED ON INVOICE". contains true and accurate descriptions of the waste.All relerd <br /> vant information rega - <br /> ing known or suspected hazards associaW with the waste has been disclosed. <br /> I also acknowledge that I have read and agree to the terms on the reverse side <br /> TSDF: Evergreen Oil, Inc. of this form. <br /> 6880 Smith Avenue Pursuant to Tale 22,Section 66264.12,Evergreen Oil,Inc,Evergreen <br /> Newark, CA 94560 Environmental Seryices,has the appropriate permits for and will accept <br /> the wastes mamfea to Evergreen facilities so long as it meets the <br /> E/PA#CAD980887418 approved t/ criyteria. / <br /> DRIVER ROUTE# DRIVER SIGNATURE GE "TOR'S SIGNATURE PRINT NAME <br />