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12 <br />48 P Evergreen Environmental Services <br />/ dedicated to the protection of the environment <br />O <br />Q 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 />Rig I INC INC00MaTa"N <br />Bill of Lading <br />Pv:. 758914 <br />96Ya 7l <br />Date �' ��-- 5;5 — <br />NAME <br />Co« n 4 - /JJ 1 �+ <br />NAME V <br />CASA ❑ CHECKD <br /># <br />ADDRESS <br />ISIS �O vjN ��1`�iil <br />Used Automotive Antifreeze, Non-RCRA Huardous <br />Waste, <br />CL'S'r0!1lER C01) NO. <br />✓7• <br />Gal <br />CDn//D <br />C STA"1'E ZIP CO <br />CIT'" STATE ZIP CO <br />PO n <br />PHONE NQ <br />PHONE NO. PROFILE NO. <br />CUSTOMER EPA IU NO. <br />a3-- 4-.1o3 <br />( <br />Gal <br />PRODUCT <br />Used oil, Non-RCRA Hazardous Lubricating <br />Waste, Liquid Industrial <br />WASTE MANIFEST <br />CODE NUMBER <br />CA 221 <br />CA 221 <br />QUANTITY <br />UNITS PRICE AMOUNT <br />( For Time Of Service Only) <br />GH <br />Gal <br />Used Automotive Antifreeze, Non-RCRA Huardous <br />Waste, <br />CA 134 <br />Gal <br />Waste <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993 In (Oil contaminated with halogens) <br />CA 22I <br />10011 12 <br />Gal <br />Oil & Water, Nosy-RCRA Hazardous Waste, Liquid <br />CA221 <br />Gal <br />Wage Solids and Sludgy <br />GM <br />Wash-out <br />lbramod Used Oil Filters <br />?Jon-RCRA hazardous Waste Solids (oily debris) <br />CA 227umm <br />Drum <br />Empty Drums <br />- <br />Drum <br />Transportation <br />I firs. <br />Other. <br />Other: <br />Other. <br />Otho: <br />Otixr <br />Other: <br />other. <br />Otter: <br />TEST PASS ❑ <br />FAII. ❑ PPM <br />lest <br />❑ Collection Station ❑ Agricultural Source <br />11 Government Source ❑Industrial Source <br />❑ Mann Source <br />TOTAL <br />CHARGES <br />"THIS IS NOT AN INVOICE; YOU WILL <br />RECEIVE AN INVOICE FROM OUR <br />ACCOUNTING DEPT. PAYMENT AT TIME OF <br />SERVICE WILL 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 />17RiVER ROUTE #<,—,DRIVER SIGNATURE <br />1 hereby ecnify that all information in this and all attached documents <br />contains true and accurate descriptions of the waste. All relevant infonna ion regard- <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,Section 66264.12. Evergreen Oil, Inc, Evergreen <br />Environmental Services, has the appropriate permits for and will accept <br />the wastes WrufestePoEvergreen facilities so long as it meets the <br />app d a4*ptanc4 criteria. <br />[it V <br />/V <br />' ((V <br />.tG (�G` <br />GE RAT R'S S GNATURE PRINT NAME <br />