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Evergreen Environmental Services <br />dedicated to the protection of the environment <br />To schedule a pickup, call Send Ila)mtCnl to: <br />800-972-5284 Evergreen <br />6880 Smith Ave., Newark, CA EPA# CA0982413262 P.O. Box 49065 <br />16540 S. San Pedro St., Carson, CA EPA# CAD982413262 San lose, CA 95161-9065 <br />]OR LOCATION <br />RILLING INFORMATION <br />Bill of Lading <br />737524 <br />Sales Order # 901_3r h=/yS <br />Date _�=oZ-o2 _5 ; <br />NAM; <br />Used oil, Non-RCRA Hazardous Lubricating <br />Waste, liquid Industrial <br />CA 221 <br />NAME <br />CASH ❑ CHECK[] <br />CA 221 <br />(,at <br />O CGly 4 <br />/ f/'d N <br />Used Automotive Antifreeze, Non-RCRA Hazardous <br />Waste, Liquid <br />CA 134 <br />ADDRESS <br />ADDRESS <br />CA 221 <br />1wil UD2 <br />CUSTOMER CODE NO. <br />/S/-5- <br />,®.� <br />f� <br />Oil & Water, Non-RCRA Hazardous Waste, Liquid <br />C'.p <br />CITY <br />STATE <br />711, CO <br />CITY <br />S'I'A'hF. %A' CO <br />POIt <br />le e4 <br />e;f <br />f 33 6 <br />Gal <br />2-776(o <br />PHONE NO. <br />PHONE NO. <br />Each <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />0?.3` — dy <br />0-4 <br />6 <br />IhtunS <br />ev <br />PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br />CODE NUMBER ( For Time Of Service Only) <br />Used oil, Non-RCRA Hazardous Lubricating <br />Waste, liquid Industrial <br />CA 221 <br />Gat <br />CA 221 <br />(,at <br />Used Automotive Antifreeze, Non-RCRA Hazardous <br />Waste, Liquid <br />CA 134 <br />(jai <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993111(Oil contaminated with halogens) <br />CA 221 <br />1wil UD2 <br />Gal <br />Oil & Water, Non-RCRA Hazardous Waste, Liquid <br />CA221 <br />- t <br />Gal <br />Waste Solids and Sludges <br />'� ", vi"•! <br />Gal <br />Wash-out <br />'- <br />Each <br />Drained Used Oil Filters <br />6 <br />IhtunS <br />ev <br />Non-RCRA Hazardous Waste Solids (oily debris) <br />CA 223 <br />Drum <br />Empty Drone; <br />Drunt <br />I tansportatiun <br />Jim. <br />Otter: <br />Other: <br />(riper: <br />Other - <br />Otter: <br />Other: <br />Other: <br />Other: <br />'FEST PASS ❑ FAIL <br />❑ PFM Test <br />❑ Collection Station ❑ Agricultural Source <br />❑ Government Source ❑ hrdushial Source <br />❑ Marine Source <br />, �/ �r�./w �, <br />1 <br />r H AR • E S <br />//Q 0V1 <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 />I hereby certify that all information in this and all attached documents <br />contains we 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 Title 22,Section 66264.12, Evergreen Oil, Inc, Evergreen <br />Environmental Services. has the appropriate permits for and will accept <br />the wastes manifested to Evergreen facilities so long as it meets the <br />approved acceptance criteria. <br />DRIVER ROUTE # c54MVER SIGNATURE GENERATOR'S <br />PRINT NAME <br />