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#'EVergreen <br />Environmental Services <br />dedicated to the protection of the environmentn To schedule a pickup, call Send payment to: <br />lmI W 800-972-5284 EverVeen <br />6880 Smith Ave., Newark, CA EPA# CAD982413262 P.O. Bax 49065 <br />16540 S. San Pedro St., Carson, CA EPA# CAD982413262 San Jose, CA 95161-9065 <br />JOB LOCATION <br />BILLING INFORMATION <br />1�4:;'3/6ise <br />Bill of Lading / Invoice <br />INVOICE 692607 <br />NAME <br />r <br />rs <br />NAME <br />QUANTITY <br />CASH ❑ CHECK❑ <br /># <br />ADDRESS <br />Used ail, Non-RCRA 11 f dour Lubricating <br />Waste. Liquid Indnstrial <br />ADDRESS <br />g7LO5-1 A+er <br />CIISTOMh1R CODE NO. <br />1515- AD. <br />t <br />CA 221 <br />c•JN.ioZ <br />CITY <br />81 ATE, ZIP CO <br />CITY <br />ST'A'TE ZIP Co 1 <br />o <br />1 !o <br />C1 221 <br />RX)LI Ml2 <br />PHONE NO. <br />9)' 51 <br />G <br />PRONE NO. <br />CAMI <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />L4Z_Z)root1sv- <br />I <br />PRODUCT' / �(j <br />f J9 Z — 4::9_4 <br />WASTE <br />CODE <br />MANIFEST <br />NUMBER <br />QUANTITY <br />UNITS PRICE <br />AMOUNT <br />Used ail, Non-RCRA 11 f dour Lubricating <br />Waste. Liquid Indnstrial <br />CA221 <br />g7LO5-1 A+er <br />rJ <br />Gal <br />t <br />CA 221 <br />Gal <br />Used Automotive Antifreeze,Non-RCRA hazardous <br />Waste, Liquid <br />CA Ia4 <br />(rat <br />/, <br />RQ Waste Combustible Liquid, N.U.S. NA <br />1993 OI ((')il wuwminated with halogens) <br />C1 221 <br />RX)LI Ml2 <br />Gal -- <br />Oil & Ritter, Non-ACRA hazardous Waste, liquid <br />CAMI <br />Gal <br />Waste Solids and Sludges <br />Gal <br />Wash -mit <br />I':.Ch <br />Drained I rsed Oil Filters <br />Ilium <br />Nun-RCRAHazardous Waste Solids (oily debris) <br />CA 223 <br />Drum <br />ISmpty Drums <br />Transportation <br />)hunn <br />IGs. <br />Other: <br />Other: <br />r;,,,i <br />Other: <br />Other: <br />Other: <br />Other' <br />Other: <br />finer! <br />ZTES" —, PASS <br />J <br />IAII. ❑ .?�a PPM <br />/ 'I'csl <br />(nicetiou Shdiun <br />❑ Gu ��m &nnco ❑ ludustrial Snurcc <br />0 lodusubnml S" ne <br />❑ M1Lvine'SonreaJ <br />� <br />NET T <br />7 DAYS0111 <br />'OTA � <br />ARGE <br />CJ <br />Accounting Office Office 949-757-7YWQ___SJenrse Pay From This Invoice <br />TSDF: Evergreen Oil, Inc. I hereby certify that all information submitted in this and all attached documents <br />6880 Smith Avenue contains true 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 />Newark, CA 94$60 <br />further serves as notification Ilial the above liquid wastes are banned from land <br />EPA# CAD980887418 disposal pursuant to Title 22 Section 66268.7 (a) (10). 1 also acknowledge that 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 two Evergreen facilities. <br />w/ <br />ROUTE # DRIVE SIGNATURE GENERATOR'S SIGNATURE PRINT NAME <br />