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.+ To schedule a pickup, call • t - • • I' <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 Date <br /> JOB LOCATION BILLING INFORMATION <br /> NAME <br /> NAME CASH ❑ CHECK[] <br /> L Ck!�_ -7- # <br /> ','kDDRESt 7 ADDRESS CUSTOMER CODE NO. <br /> tef <br /> CITY STATE ZIP CO CITY STATE ZIP COd <br /> 65LAQ Lord 5-3;Zf-P <br /> HONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. <br /> ( ) <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER (For Time Of Service Only) <br /> Used oil,Non-RCRA Hazardous Lubricating CA 221 Gal <br /> Waste,Liquid Industrial CA 221 Gal <br /> Used Automotive Antifreeze,Non-RCRA Hazardous CA 134 Gal <br /> Waste,Liquid <br /> RQ Waste Combustible Liquid,N.O.S.NA CA 221 Gal <br /> 1993 III(Oil contaminated with halogens) M01,y1om— <br /> Oil&Water.Non-RCRA Hazardous Waste.Liquid CA221 Gal <br /> Waste Solids and Sludges Gal <br /> Wash-out Each <br /> Drained Used Oil Filters Drum <br /> Non-RCRA Hazardous Waste Solids(oily debris) CA 223 Drum <br /> Empty Drums Drum <br /> Transportation Hrs. <br /> Other: <br /> Other: <br /> Other: <br /> Other- <br /> <hher: <br /> Other: <br /> Other: <br /> Other: <br /> TEST PASS FAIL.❑ PPM V0 tj Test <br /> ❑Collection Station jj& cultural Source <br /> ❑Government Source ndustnal Source 0 _ k ! D <br /> 7❑Marine Source / <br /> "YOU WILL ALSO RECEIVE A COMPUTER 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 SERVICE WILL contains true 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, Inc. of this form. <br /> 6880 Smith Avenue Pursuant to Title 22,Section 66264.12,Evergreen Oil,Inc,Evergreen <br /> Newark, CA 94560 Environmental Services,has the appropriate permits for and will accept <br /> the wastes m ifested to Evergreen facilities so long as it meets the <br /> EPA# CAD980887418 approved ac eptance criteria. <br /> DRINtR ROUT D �dWWfURE G NERATOR'S SIGNATURE PRINT NAME <br />