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1Evergreen Environmental Services <br />dedicated to the protection of the environment <br />w� To schedule a pickup, call Send payment to: <br />800-972-5284 Evergreen <br />6880 Smith Ave., Newark, CA EPA# CAD982413262 F.O. lloz 49005 <br />16540 S. San Pedro St., Carson, CA EPA# CAD982413262 San Jose, CA 95101-9065 <br />JOB LOCATION <br />BILLING INFORMATION <br />Bill of Lading <br />N° 758052 <br />Date_�y�. �--- <br />NAME <br />WASTE <br />CODE <br />MANIFEST <br />NUMBER <br />NAME <br />Used oil, Non-RCR1 Hazardout Lubricating <br />Waste, Liquid Industrial <br />CASH ❑ CHECK❑ <br />q <br />C <br />Used Automotive Antifreeze, Non-RCRA Hazardous <br />Waste, Liquid <br />CA 134 <br /># <br />ADDRESS <br />I <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993111(Oil contaminated with halogens) <br />M)DRESS <br />CUSTOMER CODE NO. <br />S /,5 <br />/lo /r 5 , <br />CA221 <br />approved acceptance cmeria. <br />Gal <br />/V.F 0 Z <br />CITY <br />S'1'A'IT, '7.111 <br />CO <br />CIT) ' <br />S'IAfE ZIP Co <br />Po <br />Irl - - <br />Each <br />Drained Used Oil Fillers <br />c>v6 z. <br />PHONE NO. <br />bunt <br />PHONE NO. <br />CA 223 <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />Z <br />20 <br />])turn <br />LW of tSu4. <br />// . <br />PRODUCT <br />l <br />WASTE <br />CODE <br />MANIFEST <br />NUMBER <br />QUANTITY UNITS PRICE AMOUNT <br />( For Time Of Service Only) <br />Used oil, Non-RCR1 Hazardout Lubricating <br />Waste, Liquid Industrial <br />CA 221 <br />CA 221 <br />q <br />Gal J' <br />Gat <br />Used Automotive Antifreeze, Non-RCRA Hazardous <br />Waste, Liquid <br />CA 134 <br />1 also acknowledge that I have read and agree to the terms on the reverse side <br />Gal <br />of this form. <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993111(Oil contaminated with halogens) <br />CA 221 <br />IM14= <br />('rat <br />Newark, CA 94560 <br />Oil & Water, Non-RCRA Ilazardous Waste, Liquid <br />CA221 <br />approved acceptance cmeria. <br />Gal <br />X � 1/) Q� 16nl Y� <br />Waste Sands and Sludges <br />GENE OR'S SIGNATURE V PRINT NAME <br />Gal <br />Wash-out <br />Each <br />Drained Used Oil Fillers <br />bunt <br />Non-RCRA Hazardous Waste Solids (oily debris) <br />CA 223 <br />Drum <br />Empty Drums <br />])turn <br />Transportation <br />Ilrs. <br />Other: <br />OdwT:99 <br />Oder. C <br />Other: - — -- <br />Other: <br />Other: <br />Other: <br />Other: <br />_ — ItL y PASS <br />FAIL ❑ <br />s L: PPM <br />Test Jr: 17 7 <br />Collection Station [3 Agricultural Source <br />❑ Govemmera Source ❑ Industrial Source <br />Muirte Source <br />i <br />rorrAL❑ <br />HARGES <br />rc <br />"THIS IS NOT AN INVOICE; YOU WILL <br />Accounting Office 949-757 770 <br />RECEIVE AN INVOICE FROM OUR <br />ACCOUNTING DEPT. PAYMENT AT TIME OF <br />I hereby cenily that all intonation in this and all attached documents <br />SERVICE WILL ALSO BE NOTED ON INVOICE". <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 />1 also acknowledge that I have read and agree to the terms on the reverse side <br />TSDF: Evergreen Oil, Inc. <br />of this form. <br />6880 Smith Avenue <br />Pursuant to Title 22.Scction 66264.12. Evergreen Oil. Inc. Evergreen <br />Environmental Services, has the appropriate pcmus' for and will accept <br />Newark, CA 94560 <br />the warns manifested to Evergreen facilities so long as it meets the <br />EPA# CAD980887418 <br />approved acceptance cmeria. <br />(CA -t- <br />X � 1/) Q� 16nl Y� <br />• RIVER ROUTE # DRUIVEk SIGNATURE <br />GENE OR'S SIGNATURE V PRINT NAME <br />