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AA <br />A <br />Evergreen Environmental Services <br />dedicated to the protection of the environment <br />T6 schedule a pickup, call Send payment 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 San lose, CA 95161-9065 <br />JOB LOCATION <br />BILLING INFORMATION <br />Bill or Lading <br />732150 <br />Sales Order # <br />Date j�, % 4y `)`, <br />NAME <br />WASTE <br />CODE <br />NAME <br />QUANTITY UNITS PRICE AMOUNT <br />( For Time Of Service Only) <br />CASH ❑ CHECK❑ <br />CA 221 <br />�s(ot✓% % <br />Gal <br />'LQ <br /># <br />CA 221 (,at <br />Used Automotive Antifreeze, Non-RCPA Hazardous <br />Waste, Liquid <br />CA 134 <br />ADDRESS <br />Gal <br />ADDRESS <br />CUSTOMER CODE NO. <br />CA 221 <br />FW140n <br />cr <br />Gal <br />0NZc_�Z <br />CITY" <br />STATE ZIP CO <br />CITY" <br />S'L'ATE ZIP CO <br />I'O <br />�B �533F> <br />L��S11i <br />PHONE NO. <br />PHONE NO. <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />Z <br />Drained Used Oil Filters <br />i v <br />PRODUCT <br />Z C. <br />WASTE <br />CODE <br />MANIFEST <br />NUMBER <br />QUANTITY UNITS PRICE AMOUNT <br />( For Time Of Service Only) <br />Used oil, Non-RCRA Hu dour Lubricating <br />Waste, Liquid Industrial <br />CA 221 <br />�s(ot✓% % <br />Gal <br />'LQ <br />�.SrV <br />CA 221 (,at <br />Used Automotive Antifreeze, Non-RCPA Hazardous <br />Waste, 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 />FW140n <br />Gal <br />Oil & Water, Non-RCRA Hazardous Waste, Liquid <br />CA221 <br />Gal <br />Waste Solids mid Sludges <br />Gal <br />Washout <br />Each <br />Drained Used Oil Filters <br />Drum <br />Non-RCRA Hazardous Waste Solids (oily debris) <br />CA 223 <br />Thum <br />Empty Drums <br />Drum <br />Transportation tip <br />Ills. <br />Other:,: <br />Other: <br />Other: <br />Other: <br />Other: <br />Other: <br />Other: <br />Other: <br />PASS Eir <br />FAIL ❑ <br />C PPM <br />�' 'fest <br />Collection Station ❑ Agricultural Source <br />❑ Govenunenl Source ❑ Industrial So..`l <br />❑Marine Source <br />CHARGE <br />aJ <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 />1 l�T+ <br />ROUTE # DRIVE <br />Accounting Office 949-757 <br />I hereby certify that all information in this and 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 />Pursuant to Title 22,Seclion 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 />Is-- i <br />SIGNATURE ENERATOR'S SIGNATURE PRINT NAME <br />