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j Evergreen Environmental Services <br />dedicated to the protection of the environment <br />To schedule a pickup, call Send payment to: <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 />in r OCATio!q <br />RILLING INFORMATION <br />Bill of Lading/Invoice <br />783530 <br />Sales Order # �(./ VS 3 3 7S <br />Dale //-,' -9S <br />-NAME <br />WASTE MANIFEST <br />CODE NUMBER <br />NAME <br />Used oil, Non-RCRA hazardous Lubricating <br />Waste, "Wild Industrial <br />CASA ❑ CHIiCK❑ <br />Gal <br />Gal <br />Used Autornolivu A.dif e, Non-RCRA hazardous <br />Waste, Liquid <br />CA 134 <br /># <br />ADDRESS <br />,ZIP <br />ADDRESS <br />Gal <br />COS I'OMI:R nCODE NO. <br />CITY <br />STATE CO <br />5334 <br />CITY <br />STATE ZIP CO <br />PO NN <br />3/9357 <br />PRONE NO. <br />Gal <br />PHONE NO. <br />Wed <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />PRODUCT <br />WASTE MANIFEST <br />CODE NUMBER <br />QUANTITY UNITS PRICE AMOUNT <br />( For Time Of Service Only) <br />Used oil, Non-RCRA hazardous Lubricating <br />Waste, "Wild Industrial <br />CA 221 <br />CA 221 <br />Gal <br />Gal <br />Used Autornolivu A.dif e, Non-RCRA hazardous <br />Waste, Liquid <br />CA 134 <br />Gal <br />RQ Waste Combustible liquid, N.O.S. NA <br />1993Ell (Oil contaminated with halogens) <br />CA 221 <br />FM14M <br />Gal <br />Oil&Water, Nao-RCRA Hazardous Waste, Liquid <br />CA221 <br />Gal <br />Waste Solids and Slu kes <br />Gal <br />Wed <br />Each <br />Donned Used (til Fibers <br />sl Dnrm 3. .J `'�8 <br />0 od <br />Non-RCRA Haza.r6su,; Waste Solids (oily debris) <br />CA223 <br />Drum <br />Empty Drums <br />Drum <br />Traapulal-a <br />llrs. <br />Other. <br />other. <br />011ier <br />Other. <br />ol6r. <br />Other. <br />Other <br />Other <br />TEST PASS ❑ <br />FAIL ❑ PPM <br />'fest <br />❑ Collediun Slain ❑ Agiculmral Source <br />❑ Csov..... Source ❑ Ivdnsbial Source <br />❑ marmcspa� <br />TOTAL <br />CIIARGES <br />"YOU WILL ALSO RECEIVE A COMPUTER <br />GENERATED INVOICE AND/OR <br />STATEMENT FROM OUR ACCOUNTING OFFICE. <br />PAYMENT AT TIME OF SERVICE WILL <br />ALSO BE NOTED ON INVOICE". <br />TSDF: Evergreen Oil, Inc. <br />6880 Smith Avenue <br />Newark, CA 94560 <br />EPA# CAD980887418 <br />Accounting Office 949-757-7770 <br />I hereby certify that all information in this and all attached documents <br />contains one and accurate descriptions of the waste. All relevant information regard- <br />ing known or suspected hazards associated with the waste has been disclosed. <br />I also acknowledge that I have read and agree to the terms on the reverse side <br />of this form. <br />Pursuant to Title 22,Section 66264. 12, Evergreen Oil, Inc, Evergreen <br />Environmental Services, has the appropriate permits for and will accept <br />the wastes manifests to Evergreen facilities so long as it meets the <br />apprAvpd acc(plancileria. <br />ROUTE DRIVER SIGNATURE OE T [t'S S NATURE PRINT NAME <br />