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AA <br />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 />JOB LOCATION <br />BILLING INFORMATION <br />Bill of Lading/Invoice <br />772194 <br />Sales Order # V <br />Dale <br />NAME <br />WASTE <br />CODE <br />NAME <br />QUANTITY UNITS PRICE AMOUNT <br />( For Time Of Service Only) <br />CASH ❑ CHECK❑ <br />CA 221 <br />CA 221 <br />qNUMBER <br />/ V�O t7 <br />ZSG Gal <br />Gal <br />Used Automotive AntiGeeze, Non-RCRA Hazardous <br />Waste, Liquid <br />CA 134 <br />ADDRESS <br />Gal <br />ADDRESS <br />CA 221 <br />RI014M <br />CUS'T'OMER CODE NO. <br />;15- <br />Oil & Water, Non-RCRA Hazardous Waste, liquid <br />04221 <br />try zoz, <br />CITY <br />'STATE ZIP CO <br />CITY <br />STATE ZIP CO <br />Wash-out <br />Each <br />Drained Used Oil Fillers <br />PHONE NO. <br />Drum <br />PHONE NO. <br />CA 223 <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />ZJR g <br />Drum <br />v <br />ovc+olt o <br />PRODUCT <br />Z G <br />WASTE <br />CODE <br />MANIFEST <br />QUANTITY UNITS PRICE AMOUNT <br />( For Time Of Service Only) <br />Used oil, on-RCRAH dous Lubricating <br />Waste, Liquid Industrial <br />CA 221 <br />CA 221 <br />qNUMBER <br />/ V�O t7 <br />ZSG Gal <br />Gal <br />Used Automotive AntiGeeze, Non-RCRA Hazardous <br />Waste, Liquid <br />CA 134 <br />Gal <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993 EI (Oil contaminated with halogens) <br />CA 221 <br />RI014M <br />Gal <br />Oil & Water, Non-RCRA Hazardous Waste, liquid <br />04221 <br />Gal <br />Waste Solids and Sludges <br />Gal <br />Wash-out <br />Each <br />Drained Used Oil Fillers <br />Drum <br />Non-RCRA Hazardous Waste Solids (oily debris) <br />CA 223 <br />Drum <br />Empty Drums <br />Drum <br />Transportation <br />His. <br />Other. <br />Other: <br />Other: <br />Other: <br />Other: <br />Other: <br />9 <br />011ier: <br />Other: <br />TE f PASS <br />FAIL❑ PPM <br />f 'fest /Z-_jp <br />—tion <br />Collection ❑ Agricultural Source <br />❑ Government Source ❑ Industrial Sourm <br />❑ Marine Source <br />TOTAL <br />Af <br />CIIARGE <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 />DRIVER <br />Accounting Office 757 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 apMpnate permits for and will accept <br />the wastes mmanijested tq Favergme to ilities so long as it meets the <br />approved nee c a. A <br />PRINT NAME <br />