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%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 />68M Smith Ave., Newark, CA EPA# CAD982413262 P.O. Box 49065 <br />16540 S. San Pedro St., Carson, CA EPA# CAD982413262 San lose, CA 95161-9065 <br />JOB LOCATION <br />BILLING INFORMATION <br />BVI Of LadTngAnvoice <br />769341 <br />Sates Order # <br />Date t , <br />C <br />e <br />NA. <br />WASTE <br />CODE <br />MANIFEST <br />NUMBER <br />NAME <br />Used oil, Non-RCRA Hazw4us Lubricating <br />Waste, Liquid Industrial <br />CASA ❑ CHECK❑ <br />XeZ <br />S <br />Used Automotive Antifreeze., Non-RCRA Hazardous <br />Waste. Liquid <br />C4Y)4 <br />.� <br />Gal <br />ADDRESS <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993 IH (Oil contaminated with halogens) <br />CA 221 <br />IODIdiDl <br />ADDRESS <br />CUSIUk1ER CODE NO. <br />CA221 <br />.. <br />Gal <br />Waste Solids and Sludges <br />CITY <br />STATE <br />ZIP CO <br />CITY <br />STATE ZIP CO <br />POP <br />Each <br />� <br />Drained Used Oil Filters <br />307 3 <br />PHONE NO. <br />Non-RCRA Hazardous Waste Solids (oily debris) <br />CA 223 <br />PHONE NO. <br />Drum <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />Drum <br />Transportation <br />PRODUCT / <br />6 G 3 G <br />WASTE <br />CODE <br />MANIFEST <br />NUMBER <br />QUANTITY UNITS PRICE AMOUNT <br />(Fair -rime Of Service Only) <br />Used oil, Non-RCRA Hazw4us Lubricating <br />Waste, Liquid Industrial <br />CA 221 <br />CA 221 <br />XeZ <br />—? Q Oral Zp St p =j;Z> <br />Gal <br />Used Automotive Antifreeze., Non-RCRA Hazardous <br />Waste. Liquid <br />C4Y)4 <br />.� <br />Gal <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993 IH (Oil contaminated with halogens) <br />CA 221 <br />IODIdiDl <br />Gal <br />Oil & Water, Not-RCRA Hazardous Waste, Liquid <br />CA221 <br />.. <br />Gal <br />Waste Solids and Sludges <br />Gal <br />Wash-out <br />Each <br />Drained Used Oil Filters <br />Drum <br />Non-RCRA Hazardous Waste Solids (oily debris) <br />CA 223 <br />Drum <br />Empty Drums <br />Drum <br />Transportation <br />Jim <br />Othay.. <br />Odw <br />Other: <br />011M <br />Od6 - <br />Othw. <br />Other <br />Ofl ern <br />G—�i 'ZCt..✓ PASS 19 <br />FAIL ❑ <br />PPM <br />'lest �,ap <br />Colbeion Station ❑ Agricultural Source <br />❑ ciover� so. ❑ Industrial sounez <br />❑ Marine SotnOe <br />I'OT'A L <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 94 757-7770 <br />I hereby certify that all inf in this and attached documents <br />contains true and aextaate d -c -peons o t e waste All relevav infeamarien regrad- <br />ing known or suspected hazards ascus ural with the waste has been disclosed - <br />1 also acknowtedge that I have read and apfce to the mrm ou the revvse side <br />of this form. <br />Pursuant to Title 22,Section 66264.12, Evergreen Oil. rte, Emgrern <br />Environmental Sesviees, has the appropriate permits for and will a pt <br />the wastes manifested to Evergreen facilities so long ss it meets the <br />approved acceptanee criteria. <br />I- I <br />tE/GENErS SiGNA PRINT NAME <br />