Laserfiche WebLink
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 />JOB LOCATION <br />BILLING INFORMATION <br />Bill of Lading/Invoice <br />773596 <br />Sales Order # & X3 ,PS 6' K <br />Dale s�- 30 - 95 <br />NAME <br />co <br />J iJ <br />QUANTITY <br />NAME <br />Used oil, Non•RCRA Hazardous Lubricating <br />Waste, Liquid Industrial <br />CASH ❑ CHECK[:] <br /># <br />ADDRESS <br />Gal <br />ADDRESS <br />CUSTOMER CODE NO. <br />CA 134 <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993 11(Oil contaminated with halogens) <br />CA 221 <br />IMIRM <br />CITY <br />STATE <br />ZIP CO <br />CITY <br />SPATE ZIP CO <br />PO <br />PHONE NO. <br />Waste Solids and Sludges <br />PHONE NO. <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />a 3 <br />6ao� <br />Each <br />y <br />PRODUCT <br />WASTE MANIFEST <br />CODE NUMBER <br />QUANTITY <br />UNITS PRICE AMOUNT <br />( For Time Of Service Only) <br />Used oil, Non•RCRA Hazardous Lubricating <br />Waste, Liquid Industrial <br />CA 221 <br />Gal <br />CA 221 Gal <br />Used Automotive Anti6reeze, Non-RCRA Hazardous <br />Waste, Liquid <br />CA 134 <br />Gal <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993 11(Oil contaminated with halogens) <br />CA 221 <br />IMIRM <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 />$f <br />Drums Soy(- <br />Oo <br />Non-RCRA Hazardous Waste Solids (oily debris) <br />CA 223 <br />Drum <br />Empty Drums <br />Dram <br />Transportation <br />14A <br />Othe <br />'7 <br />Other: <br />Olhet: <br />Other: <br />Other: <br />Other: <br />Other. <br />Other: <br />TEST PASS ❑ <br />FAIL ❑ PPM <br />'rest <br />❑ Collection Station ❑ Agricultural Source <br />❑ Govemomat Source urce <br />❑ Industrial So <br />❑Marine Source <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 />TSDF: Evergreen Oil, Inc. <br />6880 Smith Avenue <br />Newark, CA 94560 <br />EPA# CAD980887418 <br />Accounting Office 949-757-7770 <br />DRIVER ROUTE # W VER 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 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 manife to Evergreen facilities so long as it meets the <br />approlted afpepta ce liritegia. <br />41�i �l <br />G' ATURE PRINT NANM <br />