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Evergreen Environmental Services <br />4,0' - <br />dedicated to the protection of the environment <br />To schedule a pickup, call Send pllq,ncttt (it: <br />11 �� 800-972-5284 Evergreen <br />6680 Smit(Pve., Newark, CA EPA# CAD982413262 P.O. Box 49065 <br />16640 S. San Pedro St., Carson, CA EPA# CAD982413262 San lose, CA 95161-9065 <br />tOB LOCATION <br />BILLING INFORMATION <br />Bill of Lading <br />711085 <br />Dole �1�' <br />-,/ /c) 9t <br />��-_.. --- <br />V NAME <br />. <br />CA 221 <br />NAME. <br />Zoo <br />CASH ❑ CHECK❑ <br />u <br />9 Y <br />CA 221 <br />Ont <br />ADDRESS <br />ADDRESS <br />CI IS'I'OMER C( IDE NO. <br />O d <br />RQ Waste Combustible Liquid, N.O.S. NA i <br />1993 111 (Oil contaminated with halogens) <br />CA 221 <br />IWI II P <br />`� N Z1> <br />CITY" <br />�4 <br />STATE <br />'LIP CO <br />CITY <br />STATE ZIP CO <br />i) <br />Z�3 <br />9Sd3� <br />Waste Solids acrd Sludges <br />PHONE NO. <br />PHONE NO. <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />Z35 76ZO 3 <br />Each <br />FYAR <br />PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br />CODE NUMBER ( For Time Of Service Only) <br />Used oil, Non-RCRA Hazaillous Lubricating <br />Waste, Liquid Industrial <br />CA 221 <br />C 7Z4:;o SOCfco <br />Zoo <br />Gnl <br />u <br />9 Y <br />CA 221 <br />Ont <br />Used Automotive Antifreeze. Nan-RCRA I Iuaidous <br />Waste, Liquid <br />CA 134 <br />O d <br />RQ Waste Combustible Liquid, N.O.S. NA i <br />1993 111 (Oil contaminated with halogens) <br />CA 221 <br />IWI II P <br />tial <br />Oil & Water. Nan-RCRA hazardous Waste. Liquid <br />CA221 <br />Uel <br />Waste Solids acrd Sludges <br />Gal <br />Wash-out <br />Each <br />Drained used Oil Filters <br />Dmut <br />Nun-RCRA I hazardous Waste Solids (oily debris) <br />CA 223 <br />Dorm <br />laupty Dnmrs <br />Dnmr <br />'I ruralnnation <br />I Its. <br />Other: <br />Other: <br />Other: <br />Other <br />Other: <br />Other: <br />Other: <br />Other: <br />Trsr G _ _ZA'PASS FAIL <br />7, PPM I 'Ie <br />Collection Station ❑ Agricultural Source. <br />❑ Gvu crtunent Source [IIO• <br />Industrial Source <br />[:I Marine Source <br />l V �'A <br />CHARGES <br />71. <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# CAD9808874 <br />ROUTE# <br />Accounting Office 949- 7-7770 <br />SIGNATURE <br />I hereby certify that all informalio and all ed documents <br />contains line 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 mad and agree to the terns 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 a "nce cnlerm. <br />SIGNATURE PRINT NAME <br />