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JPEreen Environmental Services <br />dedicated to the protection of dee environinent <br />To schedule a pickup, call Send 11wslncrll hr: <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 Jose, CA 95161-9065 <br />JOB LOCATION BILLING INFORMATION <br />Bill of Lading <br />707750 <br />NAME <br />Used oil, Non-RCRA llauudous Lubricating <br />Waste, Liquid Industrial <br />CA 221 <br />NAME, <br />CASA ❑ CHECK❑ <br />' b X <br />/J,feS.i <br />CA 221 <br /># <br />)DRESS t <br />l Ised Automotive Anlilicczc, Non-RC'RA Ilazarduus <br />Waste, Liquid <br />ADDRESS <br />Cl I.S'I 0\11:1? CODE; NO. <br />/S/,5 N <br />RQ Waste Combustible Liquid, N.O.S. NA I <br />1993111(Oil contaminated with halogens) <br />CA 221 <br />full[ RUM <br />G0AJ/0,;l— <br />C'1'I'Y <br />CI I*Y <br />STATE <br />ZIP CO <br />CITY <br />S77\'1'F. ZIP CO <br />PO H <br />a6 <br />917 <br />PHONE NO. <br />PHONE NO. <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />9 3°— <br />o <br />) <br />4 <br />Drained Used Oil FillersThum,(------ <br />PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br />CODE NUMBER (For Time Of Service Only) <br />Used oil, Non-RCRA llauudous Lubricating <br />Waste, Liquid Industrial <br />CA 221 <br />Oal <br />CA 221 <br />Gal <br />l Ised Automotive Anlilicczc, Non-RC'RA Ilazarduus <br />Waste, Liquid <br />CA CW <br />Gal <br />RQ Waste Combustible Liquid, N.O.S. NA I <br />1993111(Oil contaminated with halogens) <br />CA 221 <br />full[ RUM <br />Gal <br />Oil & Water, Non-RCRA IlazArdous Waste. Liquid <br />CA221 <br />Gal <br />Waste Solids mrd Sludges <br />Gal <br />Wash-out <br />Each <br />Drained Used Oil FillersThum,(------ <br />Noul RCRA Hazardous Waste Solids (oily debris) <br />CA 223 <br />Empty Dmnrs <br />r' O; . <br />Irmo <br />_— <br />'transportation <br />I lts. <br />Other <br />etir/1 J1 <br />(hirer: <br />Otter: <br />Other <br />Other: <br />Other: <br />Other: <br />Older: <br />TEST PASS ❑ FAII. <br />❑ 111M 'lest <br />❑ Collection Station ❑ Agricultural Source <br />❑ Government Source El Industrial Source <br />[3 Marine Source <br />A <br />T r/ l � F \ I i <br />` + ) <br />/'\ <br />V <br />to <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 />EIRN R ROUTE#,5DRIVER SIGNATURE <br />I hereby certify that all infomration in this and all attached documents <br />contains true and accurate descriptions of the waste. All relevant inhnnvtlion reg:ud- <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 [his form. <br />Pursuant to Tille, 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 />GENERATOR'S SIGNATURE PRINT NAME <br />