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Evergreen Environmental Services <br />dedicated to the protection of the env(ronotent <br />To schedule a pickup, call Send pa.) ment 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 Jose, CA 95161-9065 <br />JOB LOCATION <br />BILLING INFORMATION <br />91(o5yV'9Z5 <br />Bill of Lading / Invoice <br />INVOICE 7045 <br />38 <br />Dale I��V`/ I♦ -1-91„i_. <br />NAME <br />C- <br />MANIFEST <br />NUMBER <br />QUANTITY <br />NAME <br />AMOUNT <br />CASH ❑ CHECK❑ <br />CA 221 9, <br />CA 221 <br />7 zov/ej <br />tial <br />AUURESS <br />Used Automotive Antifreeze, Non-RCRA Hazardous <br />Waste. Liquid <br />ADDRESS <br />CUSTOMER CODE NO. <br />Oat <br />A <br />, . <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993 Ill(Oil contaminated with halogens) <br />CA 221 <br />RVIRM <br />Ns a L. <br />CITY <br />STATE ZIP <br />CO <br />CITY <br />STATE ZIP Co <br />PO <br />C* <br />Waste Solids and Sludges <br />Z`E�73 <br />PHONE NO. <br />Cial <br />`L <br />PHONE NO, <br />PROFILE NO. <br />CUSTOMER EPA I NO. <br />Each <br />y <br />Drained tNod Oil Fillers <br />Dwn, <br />PRODUCT / <br />Yjjo (,� <br />WASTE <br />CODE <br />MANIFEST <br />NUMBER <br />QUANTITY <br />UNITS PRICE <br />AMOUNT <br />Useduil, Nom-RCRA Ilazatilims Lubricating <br />Waste. Liquid Industrial <br />CA 221 9, <br />CA 221 <br />7 zov/ej <br />tial <br />(;ill <br />Used Automotive Antifreeze, Non-RCRA Hazardous <br />Waste. Liquid <br />CA 134 <br />Oat <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993 Ill(Oil contaminated with halogens) <br />CA 221 <br />RVIRM <br />Our <br />Oil & Water, Non-RCRA Hazardous Waste, Liquid <br />CA221 <br />Oat <br />Waste Solids and Sludges <br />Cial <br />Wash-out <br />Each <br />Drained tNod Oil Fillers <br />Dwn, <br />Non-RCRA hazardous Waste Solids (oily debris) <br />CA 223 <br />Drum <br />I'.mply Unurns <br />Duou <br />Iransponalion <br />I Irs. <br />Other; <br />— <br />Odrer. <br />Other: <br />Other <br />Other: <br />Other: <br />Other: <br />Other: <br />'I'E.- PASS <br />FAIL ❑ <br />PPM <br />'fest <br />Collection Station ❑ Agricultural Source <br />El Government Source ❑ Industrial Source <br />❑Marine Source <br />r.. "��� <br />�ET <br />E / v <br />j <br />,F ` TAL <br />CHARGE' <br />Accounting Office 949-75 770 P s'j"311'e Karom This Invoice <br />p <br />TSDF: Evergreen Oil, Inc. I hereby certify that all informationsy�rr�OYin this and all attached documents <br />6880 Smith Avenue contains time and accuimte desc ptiowFs i jiIYe waste. All relevant information regard - <br />Newark, CA 94560 ing known or suspected hazards dsUlaled with the waste has been disclosed This <br />further serves as nounfic, 'll(VKSIt the above liquid wastes are banned train land <br />EPA# CAD980887418 disposal pursuant to Ti <br />IN <br />66268.7 (a) (10). 1 also acknowledge dun I have <br />read and agree to the terms on the reverse side of this form. Pursuant to Title 22, <br />Section 66264.12, Evergreen Oil, Inc. has the appropriate permits for, and will accept <br />the wastes manifested to Evergreen facilities. <br />ROUTE # DRIVER GNATURE / GENERATOR'S SIGNATURE PRINT NAME <br />