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wergreen Environkntal Se► -vices <br />dedicated to the protection of the environment <br />To schedule a pickup, call Send 11:q mens to: <br />800-972-5284 Evergreen <br />6880 Smith Ave., Newark, CA EPA# CAD982413262 P.O. Boz 49065 <br />16540 S. San Pedro St., Carson, CA EPA# CAD982413262 San Jose, CA 95161-9065 <br />JOB LOCATION <br />BILLING INFInRMA.'1'InN <br />[fill or Lading <br />H !44301 <br />NAM' <br />� <br />NAME <br />— o <br />CASA ❑ CIIECK❑ <br />CA 221 <br />Gal <br />ADDRESS <br />:v)URI•SS <br />CA 134 <br />CUSTOn1ER CODE NO. <br />(ial <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993111(Oil contaminated with halogens) <br />�/V-; Z <br />LITS• <br />STNIE ZII' C( <br />C'1'I'1' <br />Sli—lM ZIP CO <br />Pal <br />CA221 <br />Gal <br />----- <br />PFIONE NO. <br />PUONF. NO, <br />Gal <br />PROFILE NO. <br />CUSTOMER EPA 11) NO. <br />Washout <br />Each <br />i <br />Ihmn <br />v a <br />PRODUCT jJ�� si WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br />• / /1'J`� G CODE NUMBER (Por'ISme Of Service Only) <br />Used oil, Non- CRA ti us Lubricating <br />Waste, Liquid Industrial <br />CA 221 S" <br />— o <br />in, <br />CA 221 <br />Gal <br />Used Automotive Ant' ze, Non-RCRA Hazardous <br />Waste, Liquid <br />CA 134 <br />(ial <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993111(Oil contaminated with halogens) <br />CA 221 <br />1001A JU2 <br />Gal <br />Oil R Water, Non-RCRA Hazardous Waste, Liquid <br />CA221 <br />Gal <br />----- <br />Waste Solids and Sludgy <br />Gal <br />— <br />Washout <br />Each <br />Drained Used Oil Filters <br />Ihmn <br />Non-RCRA Hazardous Waste Solids (oily debris) <br />CA223 <br />Urum <br />Ehilsty Drum <br />Urum <br />7'f r portatiM <br />ilrs. <br />-- <br />Crams: <br />Odrer: <br />t <br />— <br />Other: <br />Other. <br />Opfer <br />Oliver: <br />I <br />illOther:.__Other: <br />v /y <br />PASSFNL❑ prM DMIZI <br />41t <br />Collection Station <br />❑ Agricultural Source❑ Oovanmcnt Source ❑Industrial Source ❑ Marine Source <br />/' <br />- <br />_C�v05) •E7V <br />"THIS IS NOT AN INVOICE; YOU WILL Accounting Office 949-75 7770 <br />RECEIVE AN INVOICE FROM OUR <br />ACCOUNTING DEPT. PAYMENT AT TIME OF I hereby cenif) stmt all of on,air un in this and all anachrd d, K'uments <br />SERVICE WILL ALSO BE NOTED ON INVOICE". ontams true and aecumte 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 />TSDF: Evergreen Oil, Inc. orthlsfo-m. <br />6880 Smith Avenue Pursuant to Title 22,Sectinn 662(A I?. Evergreen Oil, Inc. Evergreen <br />Newark, CA 94560 Environmental Services, has the appropriate permits far and will accept <br />the wastes manifested to Evergreen facilities so lung as it meets the <br />EPA# CAD980887418 approved acceptance criteria. <br />pe '\1 - ZE) 5e,01v Y/6� <br />RIVER ROUTE # DRIVE SIGNATURE GENERArTOR•S SIGNATURE_ PRINT NAME <br />FILE COPY l/ <br />