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J10" <br />Ev r reen 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# CA0982413262 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 Lading/Invoice <br />778839 <br />Sales Order # <br />Date (f2e, <br />NAME <br />WASTE <br />CODE <br />MANIFEST <br />NUMBER <br />NAME <br />Llsed uil, Non-RCRA H us lubricating <br />Waste, Liquid Industrial <br />CASH ❑ CHECK❑ <br />V V Gal <br />_ JG <br />CA 221 Gal <br />Used Automotive Antifreeze, Non-RCRA Hazardous <br />Waste, Liquid <br />CA 134 <br />EPA# CAD980887418 <br />Gal <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993 HI (Oil contaminated with halogens) <br /># <br />2 <br />Oil & Water, Non-RCRA Hazardous Waste, Liquid <br />CA221 <br />ADDRESS <br />Waste Solids and Sludges <br />ADDRESS <br />CUSTONIF R CODE NO. <br />s <br />Washout <br />Each <br />N rt, <br />CITY" <br />STATE <br />ZIP CO <br />CITY" <br />STATE ZIP CO <br />Non-RCRA Hazardous Waste Solid,(oily debris) <br />(ZA <br />Drum <br />Empty Drums <br />3 <br />Ilium <br />s <br />Transportation <br />ISU <br />PHONE NO. <br />Other. <br />PHONE NO. <br />PROFILE NO. <br />CUSTOMER EPA HINO. <br />Other: <br />f <br />Other: <br />C4G -v I oa - <br />171 <br />PRODUCT V <br />WASTE <br />CODE <br />MANIFEST <br />NUMBER <br />QUANTITY UNITS PRICE AMOUNT <br />( For Time Of Service Only) <br />Llsed uil, Non-RCRA H us lubricating <br />Waste, Liquid Industrial <br />CA 221Zj7jy1 <br />V V Gal <br />_ JG <br />CA 221 Gal <br />Used Automotive Antifreeze, Non-RCRA Hazardous <br />Waste, Liquid <br />CA 134 <br />EPA# CAD980887418 <br />Gal <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993 HI (Oil contaminated with halogens) <br />CA 221 <br />lWiRm <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 />- d <br />Drum <br />Non-RCRA Hazardous Waste Solid,(oily debris) <br />(ZA <br />Drum <br />Empty Drums <br />Ilium <br />Transportation <br />40 <br />Ilrs. <br />Other. <br />Other: <br />f <br />Other: <br />Other: <br />Other. <br />Other: <br />Olh <br />Olh <br />PASS <br />FAIL <br />too PPM <br />Test `j, pp <br />-- 00 <br />Collection Station ❑ Agricultural Source S <br />❑ Government Source ❑ Indtusrial Source <br />❑ Marine source <br />TOTAL <br />AL <br />(CHARG <br />©a <br />"YOU WILL ALSO RECEIVE A COMPUTER <br />GENERATED INVOICE AND/OR <br />STATEMENT FROM OUR ACCOUNTING <br />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 �9� <br />SIGNATURE <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 regud- <br />ing known or suspected hazards associated with the waste has been disclosed. <br />I also acknowledge that 1 have read and agree to the terms on the reverse side <br />of this form. <br />Pursuant to Title 22,Seciion 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 />,/ <br />