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A <br />Evergreen Environment Al Services <br />dedicated to the protection of tire enviromnent <br />To Schedule a pickup, call Send pa} fnent 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 Sin lose, CA 95161-9065 <br />JOB LOCATION <br />BILLING INFORMATION <br />Bill of Lading <br />739208 <br />Sales Order #V (,;,J( ; `l5 ) c! 7 <br />Date �[��G'y-�� -- <br />NAME <br />/ <br />CA 221 <br />NAME <br />CASA ❑ CHECK❑ <br />C'�Jvl iy <br />AI 1,3n., <br />CA 221 <br /># <br />ADDRESS <br />Used Automotive Antifreeze, Nun-RCRA Hazardous <br />Waste, Liquid <br />ADDRESS <br />CUSTOnILR CODE; NO. <br />15-1j-.5"4 <br />r <br />RQ Waste Combustible Liquid, N.O.S. NA <br />199316 (Oil contaminated with halogens) <br />CA 221 <br />IMI/Iin2 <br />r-Y'l i- <br />CITY- <br />STATE <br />ZIP CO <br />CITY <br />STATE ZIP CO <br />P <br />Gal <br />Waste Solids and Sludges <br />PHONE NO. <br />' h <br />PHONE NO. <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />-� <br />p(,ijiP <br />Each <br />Drained Used Oil Filters <br />PRODUCT � ' WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br />G . CODE NUMBER ( For Time Of Service Only) <br />Used oil, Non-RCRA Hazilrdous Lubricating <br />Waste, Liquid Industrial <br />CA 221 <br />!�',r Z6- <br />Gal <br />CA 221 <br />Gal <br />Used Automotive Antifreeze, Nun-RCRA Hazardous <br />Waste, Liquid <br />CA 134 <br />Gal <br />RQ Waste Combustible Liquid, N.O.S. NA <br />199316 (Oil contaminated with halogens) <br />CA 221 <br />IMI/Iin2 <br />Gal <br />Oil & Water, Non-RCRA Hazardous Waste, Liquid <br />CA221 <br />Gal <br />Waste Solids and Sludges <br />' h <br />(Jai <br />wash-out <br />-� <br />p(,ijiP <br />Each <br />Drained Used Oil Filters <br />Drum <br />Non-RCRA Hazardous Waste Solids (oily debris) <br />CA 223 <br />llmm <br />Empty Drums <br />Dunn <br />Transportation <br />Ills. <br />other: <br />Other. <br />Other: <br />Other.- <br />ther:Other: <br />Other: <br />Other: <br />Other: <br />Other: <br />11. ES GSA-, 1PASS 16 FAIL <br />LI PI'M'fast j <br />Collection Station [I Agricultural Source <br />1771Gov ant Source ElIndustrial Source <br />El Marine Source <br />/ A <br />`� ' ^ <br />7` 1 1 A ` G E <br />_ <br />/-7-7 "ry <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 />t ROUTE # DR <br />Accounting Office 94 -757 7770 <br />I hereby certify that all information in Iftls nn all attached documents <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 />I also acknowledge that I have read and agree to the terms on the reverse side <br />of this form. <br />Pursu <br />lint to t1e 2 Section 66264.12, Evergreen Oil, Inc, Evergreen <br />Envir nul Services, has lire appropriate permits for and will accept <br />thew s manifested MEvergreen facilities so long as it meets the <br />SIGNATURE <br />TUBE PRINT NAME <br />