Laserfiche WebLink
J Evergreen Environmental Services <br />dedicated to the protection of doe 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 />JOB LOCATION <br />BILLING INFORMATION <br />Bill of LadinWInvoice <br />785640 <br />Sales Order # <br />Dale I`{p✓ Z3 Wp. <br />NAME, <br />WASTE <br />CODE <br />MANIFEST <br />NUMBER <br />NAME <br />UNITS PRICE AMOUNT <br />( For Time Of Service Only) <br />CASH El CHECK[] <br />CA 221 1 Jf/ <br />CA 221 <br />q <br />3zc> <br />Gal 7-1",( <br />Gal <br />O <br /># zo <br />CA 134 <br />/ <br />Gal <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993111(Oil contaminated with halogens) <br />ADDRESS <br />IADDRESS <br />Gal <br />CUS'I.OMER CODE NO. <br />5 s <br />644H8LLAZZ <br />Gal <br />Waste Solids and Sludges <br />Ci,r,r, <br />STARE <br />LIP CO <br />ClI Y <br />S"IWI E ZIP CO <br />Washout <br />Each <br />Drained Used Oil Filters <br />PHONE NO. <br />Z <br />PHONE NO. <br />PROFILE NO. <br />4 <br />cusT6MER EPA ID NO. <br />PRODUCT/ <br />`� `0<-- <br />WASTE <br />CODE <br />MANIFEST <br />NUMBER <br />QUANTITY <br />UNITS PRICE AMOUNT <br />( For Time Of Service Only) <br />ar <br />Used oil, Non-RCRA Hazdo s Lubricating <br />Waste, Liquid Industrial <br />CA 221 1 Jf/ <br />CA 221 <br />q <br />3zc> <br />Gal 7-1",( <br />Gal <br />O <br />Used Automotive Antifreeze, Nun-RCRA Hazardous <br />Waste, Liquid <br />CA 134 <br />Gal <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993111(Oil contaminated with halogens) <br />CA 221 <br />10011012 <br />Gal <br />Oil & Water, Non-RCRA Hazardous Waste, Liquid <br />CA221 <br />Gal <br />Waste Solids and Sludges <br />Gal <br />Washout <br />Each <br />Drained Used Oil Filters <br />Drum <br />Non-RCRA Hazardous Waste Solids (oily debris) <br />CA 223 <br />Drum <br />[imply Drums <br />Thum <br />Transportation <br />IIrs. <br />Other: <br />Other: <br />Other: <br />Other: <br />Other: <br />Other: <br />Other: <br />Other: <br />'f F. G PASS <br />FAIL ❑ <br />PPM <br />/ Test <br />�� • ,7p <br />/S pf> <br />Collection Station ❑ Agricultural Source <br />Govemrnt Source ❑ Industrial Source <br />❑ m <br />(]Marvte sourceI <br />( <br />TOTAL <br />CHARGES' <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 />Evergreen Oil, Inc. <br />6880 Smith Avenue <br />Newark, CA 94560 <br />EPA# CAD980887418 <br />ROUTE # <br />Accounting Office 949-7 -7770 <br />I hereby certify that all information in this and all attached documents <br />contains true 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 manifested to Evergreen facilities so long as it meets the <br />approved Acceptrrlee criic�). I <br />La (nYCAhe\r--� <br />TUBE PRINT NAME <br />