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1+.verg efei>tf to the 1nolection of >fav��oa�l>I�rea>Ital� 4'll'YACenvioininew <br />cs <br />ded <br />Tu Schedule a pickup, call <br />800-972-528 f:vcrllCcll <br />6880 Smith Ave., Newark, CA FPAtt CAD982413262 P.O. Jim 4900.1 <br />16540 S. San Pedro St., Carson, CA EPAN CAD982413262 San .lose. CA 95101-4005 <br />JOB LOCATION BILLING INFOR <br />NAnn; <br />AUDIT I•:SS AUUI(r:SS— - <br />CI'I'S SjXI F. LII' CU I C'll'Y <br />PIIONE NO. <br />Bill 0Lsldlleg <br />`51-5 <br />S;)It`s th deli ff <br />Dale ��'7h✓' ..I r�_7_/—__ _ _ ___ <br />('ilio i:l. l <br />N <br />—�- -----(-,ISI( lAlr R t-OUF: NO <br />I1/L <br />C'O U Z <br />-'-- -' - — .. _ . <br />STA I'P: /Ip <br />--- Z17 <br />I'RUFILE NQ CUSIUhIER EI'A IU PK1. <br />PRODUCT g WASTE MANIPES'I' QUANT I -Y UNITS PIU(h Aoll1UNI <br />C L CODE NUMBER (I nr'finle Ohs ice onl) ) <br />ltsed oil,Nun-RCRA IIazarJu s Lubricating <br />Waste, Liquid Industrial <br />CAM <br />Oal <br />l Tal <br />CA 221 <br />('A I74 <br />-- ------ <br />Used Aulonn+live. Ardilieeze, Non-RCRh I lazanlons <br />Waste, Liquid <br />___ <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993 QI (Oil contaminated with halogens) <br />_ <br />C'A 27.1 <br />IM,RU2 <br />lint <br />Oil &Water, Non-RC'RA llvardous Waste. Liquid <br />CA221 <br />Onl <br />—� -- ---- <br />Waste Solidsa,d Sludges <br />----- <br />Wash-onl <br />1(101 <br />l iloni <br />Don't <br />Di um <br />Ihx. <br />-- <br />Drained Used Oil Fillers <br />Non-RCRA I lazardous Waste Solids (oily debris) <br />CA 227 <br />Empty Dnmvs <br />.._ <br />Transpndnalio <br />Other: <br />--- <br />— <br />-- <br />Other: <br />Other: <br />Other: <br />(riper: <br />Other <br />I1•. G ���,/ PASS ' FAIL❑�I'M 'I'cs—_.._.._— <br />Collea lion Station ❑ Agricultural Snitl'ee <br />❑ Oovernn,enl Source ❑ Industrial Source <br />❑ Marine Source <br />� <br />tit I 1 A W's <br />"TRIS 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=7-ilry iiu <br />I hereby certify Hiatt all inOr"13 "a in 111" and all attached Joeuacws <br />contains true ,all accurate descriptiuus of the waste. All relevant information regrad- <br />ing known or suspected hazards associate) with the waste has Ixen disclosed. <br />1 also acknowledge that l have read and agree to the leans nn the reverse side <br />or ads Form. <br />pursuant 10 *title 22,Section 66264.12, Evergreen Oil, bra, Evergreen <br />Environmental Services, has the appropriate permits for and will accept <br />the wastes manifeested to Evergreen facilities so long as itirlr� the <br />approved ncce me criteria. <br />' //����- C��GIrIrPr� <br />ROUTE # DRIVVA SIGNATURE GENERATOR'S SIGNATURE P hIE <br />