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0,4 <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# CAD98203262 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 />Bill of Lading <br />Nu 758914 <br />7�Yb S(11rL <br />Date --- <br />NAME <br />NAME <br />CASH ❑ CIIEC6❑ <br />Q;u. �e <br />UNITS PRICE AMOUNT <br />( For Time Of Service Only) <br />Used oil, Non-RCR1 Hazardous Lubricating <br />Waste, Liquid Industrial <br />ADllRE55 <br />.V)URIiSS <br />CUSTOMER CODE NO. <br />/S A_/d,•rra o.. •%) J <br />(fO/tlf/0..L- <br />CITY STATE ZIP CO <br />��/2.7 -;4e C- I C-" 4 C <br />CI"I'Y SIAIT: ZIP CO <br />14)n --!' <br />�X )� 5 <br />PHONE NO. <br />PHONE NO. <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />;1 0,3 <br />Gal <br />PRODUCT <br />WASTE <br />CODE <br />MANIFEST <br />NUMBER <br />QUANTITY <br />UNITS PRICE AMOUNT <br />( For Time Of Service Only) <br />Used oil, Non-RCR1 Hazardous Lubricating <br />Waste, Liquid Industrial <br />CA 221 <br />CA 221 <br />Gal <br />Gal <br />Used Automotive Antifreeze, Non-RCRA Hazardous <br />Wast 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 />IMLIU12 <br />Gal <br />Oil & Water, Non-RCRA Hazardous Waste, Liquid <br />CAMI <br />Ciel <br />Waste Solids and Sludges <br />Gal <br />Wasb-out <br />'. {• ^. <br />n r <br />Each <br />Drained Used Oil Filters h- a� <br />X11 !t t <br />:i:: <br />G� J„I�41, <br />Drums <br />Non-RCRA hazardous Waste Solids (oily debris) - <br />CA 223 <br />Drum <br />Empty Drums <br />Drum <br />Transportation <br />Urs. <br />Other: <br />Other: <br />OtIM: <br />Other: <br />Other: <br />Other: <br />Other: <br />Other: <br />TEST PASS ❑ <br />FAIL <br />PPM <br />'fest <br />❑ Collection Station ❑ Agricultural Source <br />Government Source ❑ Industrial Source <br />❑ Marine Source <br />e p t, a <br />L❑ <br />N � N / St <br />pp ++ <br />e ,a IMP', <br />7Y��/1RA�F lt.S <br />CI <br />/" C <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 />L hereby certify that all information in this and all attached chwumens <br />contains tate 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 Tide 22,Section 66264.12. Evergreen Oil, Inc, Evergreen <br />Environmental Services, has the appropriate permits for and will accept <br />the wastes nj:``ntfeste410 Evergreen facilities so long as it meets the <br />apprgtYgl ael,ptancc(criteria. <br />IRMIR�� ROUTE # f— I� NATURE GE'Y RA1F R'S S�GNATURE �l, PRINT NAME <br />