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.AllJ Evergreen Environmental Services <br />dedicated to tire protection of the environment <br />To schedule a pickup, call Send Pa.1,nent In: <br />800-972-5284 Evergreen <br />6880 Smlth 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 Lalling i Invoice <br />INVOICE 694262 <br />Dale -r-5�-- --- <br />NAME: <br />I lsed ml, Non.RCRA Hazardous IA6ncating <br />Waste, Liquid Industrial <br />CA 221 <br />NAME. <br />cal <br />CASH ❑ C•IMCk❑ <br />(/f� <br />l...Danp'h <br />J N <br />(;,it <br /># <br />ADDRESS <br />CA 134 <br />IV)DltFSS <br />C•1 IS 11 MIER CODE NO. <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993111(Oil contaminated with halogens) <br />�rit�/.✓ <br />(;at <br />C cJ o <br />C1'I'}" <br />STAAI: ZIP <br />C'O <br />CH'S' <br />S77\'1'E /AP CO <br />POP <br />Waste Solids mid Sludges <br />C -A <br />Oil <br />or <br />�— <br />PHONE NO. <br />PHONE Nil. <br />PROFILE NO. <br />CUSTOMER EPA ID N(l. <br />a 0 <br />'In mLl- <br />sa <br />r:+r3 <br />ZO <br />Non -RC RA Hazardous Waste Solids (oily debris) <br />CA 223 <br />PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br />CODE NUMBER <br />I lsed ml, Non.RCRA Hazardous IA6ncating <br />Waste, Liquid Industrial <br />CA 221 <br />cal <br />CA 221 <br />(;,it <br />Used Automotive Antifreeze, Nml-RCRA Fl:uanlous <br />Waste, Liquid <br />CA 134 <br />(int <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993111(Oil contaminated with halogens) <br />CA 221 <br />R%)1 RX12 <br />(;at <br />Oil At Water, Non-RCRA flazardous Waste. Liquid <br />CAMI <br />cal <br />Waste Solids mid Sludges <br />Oil <br />Wash-oul <br />Each <br />Drained (Iced Oil Filters <br />$�6� <br />'In mLl- <br />sa <br />r:+r3 <br />ZO <br />Non -RC RA Hazardous Waste Solids (oily debris) <br />CA 223 <br />Drum <br />Empty Dmins <br />Dr u i <br />Transportation <br />IIrs. <br />Olhe, <br />Other: .. <br />1 ... <br />Other: <br />Other: <br />Other: <br />Other: <br />Other: <br />Other: <br />'II;S"I' PASS ❑ FAH. ❑ EEM 'I'esl <br />❑ Collection Station ❑ Agricultural Source <br />❑ Govenunvat Source ❑ Industrial Source <br />❑Marine Source <br />( A <br />z., DAYS <br />t IJ� f v a ^�I F "'L <br />CII AI <br />//e9 G+r✓ <br />Accounting Off lee 949-757-7770 Please Pay From This Invoice <br />TSDF: Evergreen Oil, Inc. <br />6880 Smith Avenue <br />Newark, CA 94560 <br />EPA# CAD980887418 <br />DkIVER ROUTE # IVER SIGNATURE <br />I hereby certify that all information submitted in [his and all attached documents <br />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 />further serves as notification that the above liquid wastes are banned from land <br />disposal pursuant to Title 22 Section 66268.7 (a) (10). 1 also acknowledge that 1 have <br />read and agree to the terms on the reverse side of this form. Pursuant to Title 22, <br />Sectio q 662(1.4.12, Drgreen Oil, Inc. has the appropriate permits for, and will accept <br />the sy: tes I nifes d o ETergreen facilities. <br />