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J Evergreen Environmental <br />dedicated to (lie t <br />To schedule a pickup, call Send pa}ntcnt 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 />Bill of Lading / Invoice <br />INVOICE 701291 <br />note f -R <br />NAME <br />r <br />6880 Smith Avenue <br />NAME. <br />CASII ❑ CIIECKD <br />Ual <br />EPA# CAD980887418 <br />disposal pursuant to Title 22 Section 66268.7 (a) (10). 1 also acknowledge that 1 have <br />Used Automotive Antifreeze, Non-RCRA Hazardous CA 134 <br />Waste, Liquid <br />i <br />AOUILESS <br />Section 66264.12, Evergreen it, Inc. has the appropriate permits for, and will accept <br />ADDRFSS <br />j <br />CI IS I ONIFR C ODE NOIs-. <br />ROUTE # DR SIGNATURE <br />t <br />Oil & Water, Non-RCRA hazardous Waste. Liquid CA221 <br />(;;it <br />_ <br />i <br />a •j4- <br />Gal <br />Z <br />CITY <br />STATE <br />ZIP CO <br />CITY <br />S At'h: ZIP CO <br />Drained Used Oil Filters <br />a <br />C <br />(v <br />Non-RCRA hazardous Waste Solids (oily debris) CA 223 _ <br />Z?1sZ�rr <br />PI ZONE NO. <br />PHONENO. <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />- - <br />ZC) 1 <br />( ) <br />LOFJOO i I S <br />PRODUCT 11, WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br />CODE NUMBER <br />Used oil, Ncml RCRA Raza ous Lubricating CA 221 J� <br />Waste, liquid Industrial CA221 <br />6880 Smith Avenue <br />Oal <br />ing known or suspected hazards associated with the waste has been disclosed. This <br />Ual <br />EPA# CAD980887418 <br />disposal pursuant to Title 22 Section 66268.7 (a) (10). 1 also acknowledge that 1 have <br />Used Automotive Antifreeze, Non-RCRA Hazardous CA 134 <br />Waste, Liquid <br />read and agree to the terns on the reverse side of this form. Pursuant to Title 22, <br />Ont <br />Section 66264.12, Evergreen it, Inc. has the appropriate permits for, and will accept <br />RQ Waste Combustible Liquid, N.O.S. NA CA 221 <br />1993 Ill (Oil contaminated with halogens) IM114UP <br />j <br />(;at <br />ROUTE # DR SIGNATURE <br />/ GENE T '. S NATUR PRINT NAME <br />Oil & Water, Non-RCRA hazardous Waste. Liquid CA221 <br />(;;it <br />Waste Solids mid Sludges <br />Gal <br />Wnsll-elft <br />Fadf <br />Drained Used Oil Filters <br />Drill <br />Non-RCRA hazardous Waste Solids (oily debris) CA 223 _ <br />Dant <br />Empty Oruills r <br />Dialm <br />transportation <br />other: <br />Other: <br />(titer: <br />(eller' <br />other: <br />Other: <br />Other: <br />OIl12r' <br />^^ <br />Y 1. 'f PASS 171 EAII. ❑ Zc G 1'I'"1 .Lesa t70 <br />Collection Station ❑ Agricultural Source <br />❑ Goverm <br />Source ❑ Industrial Source❑Marine SourceHARGES <br />.�a / ^ UA rUOTA17f <br />Enenl <br />• <br />7s% <br />Accounting Off ice 949-757 Pay From This Invoice <br />TSDF: Evergreen Oil, Inc. <br />I hereby certify that all information submitted in this and all attached documents <br />6880 Smith Avenue <br />contains We and accurate descriptions of the waste. All relevant information regard- <br />ing known or suspected hazards associated with the waste has been disclosed. This <br />further serves as notification that the above liquid wastes are banned from land <br />EPA# CAD980887418 <br />disposal pursuant to Title 22 Section 66268.7 (a) (10). 1 also acknowledge that 1 have <br />read and agree to the terns on the reverse side of this form. Pursuant to Title 22, <br />Section 66264.12, Evergreen it, Inc. has the appropriate permits for, and will accept <br />the wasKj rani ted to Ev rgr en raci 'ties. <br />j <br />ROUTE # DR SIGNATURE <br />/ GENE T '. S NATUR PRINT NAME <br />