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Evergreen Environmental Services <br />dedicated to the protection of the environment <br />To schedule a pickup, call <br />800-972-5284 <br />6880 Smith Ave., Newark, CA EPA# CAD982413262 <br />16540 S. San Pedro St., Carson, CA EPA# CAD982413262 <br />JOB LOCATION <br />Send p:lyntent to: <br />Evergreen <br />P.O. Box 49065 <br />Sat Jose, CA 95161-9065 <br />BILLING INFORMATION <br />if Pr - <br />Bill of Lading / Invoice <br />INVOICE 672128. <br />NAME/�j, <br />r <br />Al -5 <br />CA 221_177 <br />NAME <br />Zotz;I <br />C'ASII [:] C'IICCKE] <br /># <br />ADDRESS <br />S r �O <br />CA 221 <br />ADDRESS <br />CUSTOMER CODENO. <br />lr✓d <br />CA 134 <br />'PAU-C) z <br />crry <br />ZZ <br />A7 <br />s'I'A'rli an' cG <br />Crry <br />s'1Arc zlr Co I <br />ro3'77::V3 <br />21& hL14 <br />Oal <br />" �� <br />Oil & Water, Non-RCRA Hazardous Waste. Liquid <br />PHONE NO. <br />Cat <br />PIIONE NU. <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />yhof <br />2ca3 <br />}} <br />lei1�---+ <br />) <br />Wash-out <br />L`ue0 iv <br />PRODUCT G WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br />CODE NUMBER <br />Used oil, Nor-RCRAH. rduus Lubricating <br />Waste, Liquid Industrial <br />CA 221_177 <br />-Z <br />Zotz;I <br />(;;,IgJ <br />S r �O <br />CA 221 <br />(int <br />Used Automotive Anlilieeze, Nun-RC'RA Ilazardous <br />Waste, Liquid <br />CA 134 <br />(tat <br />ZZ <br />A7 <br />(Q <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993111 foil contaminated with halogens) <br />CA 221 <br />IMIAUG <br />Oal <br />Oil & Water, Non-RCRA Hazardous Waste. Liquid <br />=1 <br />Cat <br />Waste Solids and Sludges <br />Oat <br />Wash-out <br />Fach <br />Drained Used Oil Filters <br />Ilium <br />Non-RCRA Ilazardous Waste Solids (oily debris) <br />CA 223 <br />Drum <br />Rmply Drams <br />Drain <br />Transportation <br />I Its. <br />011ier: /- <br />Other: <br />i <br />Other: <br />.. d <br />,.� s/-,(,(• <br />Other - <br />Other: <br />Otter: <br />Other: <br />Otter: <br />TEST PASS FAII. ❑ PPM 'fest <br />❑ Collection Station ❑ Agricultural Source <br />❑ Government Source ❑ Industrial Source <br />I—] Marine Source <br />t 7 DAV S <br />NL'1 <br />\-1jAlZCL <br />Accounting Office 714-757-7 Ple a Pay From This Invoice <br />TSDF: Evergreen Oil, Inc. <br />6880 Smith Avenue <br />Newark, CA 94560 <br />EPA# CAD980887418 <br />DRIVER ROUTE # DRIVER SIGNATURE <br />I hereby certify that all infonnation submitted in this and all attached documents <br />contains true and accurate descriptions of the waste. All relevant infomralion <br />regarding (mown or suspected hazards associated with the waste has been disclosed. <br />*This fin -their serves as notification that the above liquid wastes are banned liven [mid <br />disposal pursumht to'I'illc 22 Section 66265.7 (a)(10). 1 also acknowledge that I have <br />read mid agfee to the lerns,on the reverse side ofthis Ibmr. <br />PRINT NAME <br />