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Ad,T. <br />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. Boz 49065 <br />16540 S. San Pedro St., Carson, CA EPA# CAD982413262 San Jose, CA 95161-9065 <br />JOB LOCATION <br />BILLING INFORMATION <br />Rill of Lading/Invoice <br />775864 <br />Sales Order # <br />Date ZZ a <br />NAME <br />Y Ys <br />Ltt 1 <br />QUANTITY <br />NAME <br />Used oil, Non-RCRA Hazar ons Lubricating <br />Waste, Liquid Industrial <br />CHECK <br />CASH El❑ <br /># <br />ADDRESS <br />Oil Z Z <br />- CJD <br />ADDRESS <br />CUSTOMER CODE NO. <br />CA 134 <br />Gal <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993111(Oil contaminated with halogens) <br />CA 221 <br />HIO1dam <br />CITY <br />STATE <br />ZIP CO <br />CITY <br />STATE ZIP CO <br />PO <br />3 l / 3 <br />PHONE NO. <br />Waste Solids and Sludges <br />PHONE NO. <br />PROFIIENO. <br />CUSTOMER EPA ID NO. <br />Washout <br />�OIA� <br />Each <br />Drained Used Oil Filters <br />1 l <br />PRODUCT/ <br />% '? <br />WASTE MANIFEST <br />CODEn NUMBER <br />QUANTITY <br />UNITS PRICE AMOUNT <br />( For Time Of Service Only) <br />Used oil, Non-RCRA Hazar ons Lubricating <br />Waste, Liquid Industrial <br />CA 221 _ l S �^� <br />Oil Z Z <br />- CJD <br />CA221 Gal <br />Used Automotive Antifreeze, Non-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 />HIO1dam <br />Gal <br />Oil & Water, Non-RCRA Hazardous Waste, Liquid <br />CA221 <br />Gal <br />Waste Solids and Sludges <br />G.] <br />Washout <br />Each <br />Drained Used Oil Filters <br />Ileum <br />Non-RCRA Hazardous Waste Solids (oily debris) <br />Empty bums <br />CA223 <br />Drum <br />Drum <br />Transportation <br />Ica <br />l im <br />Other: <br />a <br />Other: <br />Other: <br />Other <br />Other: <br />Other: <br />Other: <br />Olt er <br />TE PASS <br />FAH. Ll PPM <br />Collection Station ❑ Agricultural Source <br />❑ Government Source ❑ Industrial Source <br />El Mari no Source <br />TOTAL <br />CEIARGES <br />� <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 BF NOTED ON INVOICE". <br />Evergreen Oil, Inc. <br />6880 Smith Avenue <br />Newark, CA 94560 <br />EPAt# CAD980887418 <br />ROUTE# <br />Accounting Office 939-757-7770 <br />I hereby certify that aln�ioa all art ached documents <br />contains i e and sccsuxte 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 tcmrs on the reverse side <br />of this to. <br />Pursuant to Tide 22,Semon 66264.12, Evergreen Oil, inc, Evergreen <br />Environmental Services, has the appropriate pumirs for and will accept <br />the wastes manifested to Evergreen facilities so long as it meets the <br />approved acmIstance cn a. / <br />[E C - TOR'S SIGNATURE PRINT NAME <br />