Laserfiche WebLink
ve nvYron nentaI Services 3 4 2 2 <br /> !% dedicated to the Protection of the environment / ti, <br /> To schedule a pickup, call Send payment to: Sales Order# /e?�1/ .1 J n <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#CA0982413262 San Jose.CA 95161-9065 Date <br /> JOB LOCATION BILLING INFORMATION <br /> N ME n NAME CASH ❑ CHECK[] <br /> ADDRESS ADDRESS CUSTOMER CODE NO. <br /> l4c�� + rfL41i�'` V it�I <br /> CITY S_T l ZIP CO CITE" STATE ZIP CO PO# <br /> PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. - <br /> ` A_ <br /> 1J , <br /> PRODUCT WASTE MANIFEST` QUANTITY UNTTS PRICE AMOUNT <br /> CODE NUMBER (For Tirtie Of Service Only) <br /> Used oil,Non-RCRA Hazardous Lubricating CA 221 Gal <br /> Waste,Liquid Industrial CA 221 Gal <br /> Used Automotive Antifireeze,Non-RC RA Hazardous CA 134 Gal <br /> Waste,Li id <br /> RQ Waste Combustible Liquid,N.O.S.NA CA 221 Gal <br /> 1993,111(Oil contaminated with halogens) FOOI;m <br /> Oil&Water,Non-RCRA Hazardous Waste,Liquid CA221 Gal <br /> Waste Solids and Sludges Gal <br /> Washout Each <br /> Drained Used Oil Filters Drum <br /> Non-RCRA Hazardous Waste Solids(oily debris) CA 223 Ileum <br /> Empty Drums Drum <br /> Transportation Hrs. <br /> C_t=- <br /> Other: <br /> Other- <br /> Other- <br /> Other: <br /> ther:Other-Other: <br /> Other: <br /> Other: <br /> Other: <br /> TEST PASS FAIL❑ PPM L) Test 1 c; <br /> ❑Collection Station ❑.Agricultural Source TOTAL <br /> El Government Source )Industrial So roe 1 <br /> ❑Marine Source CHARGES � L) <br /> "YOU WILL ALSO RECEIVE A C MPUTER Accounting Office 949-757-7770 <br /> GENERATED INVOICE AND/OR <br /> STATEMENT FROM OUR ACCOUNTING OFFICE. I hereby certify that all information in this and all attached documents <br /> PAYMENT AT TIME OF SERVIC WILL contains we and accurate descriptions of the waste.All relevant information regard- <br /> ALSO BE NOTED ON INVOICE". ing known or suspected hazards associated with the waste has been disclosed. <br /> I also acknowledge that I have read and agree to the terms on the reverse side <br /> TSDF: Evergreen Oil, nc. of this form. <br /> 6880 Smith Avenue Pursuant to Title 22,Scction 66264.12,Evergreen Oil,Inc,Evergreen <br /> Environmental Services,has the appropriate permits for and will accept <br /> Newark, CA 9 560 the wastes manifested to Evergreen facilities so long as it meets the <br /> EPA# CAD980 87418 ;' approved acceptance criteria. <br /> c X <br /> -1 r141PITA TTTTc f'RNVD 8,TnPIC Ci!'-St TT TPV UDiNT NTAIAF <br />