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J <br /> �• Bill of Lading/Invoice <br /> Evergreen Environmental Services 793422 <br /> dedicated to the protection of the environment <br /> To schedule a pickup, call Send p.IN n1en! to: Sales Order # 96 :Tgel <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 t� ,7—bV <br /> JOB LOCATION BILLING INFORMATION <br /> NAME NXME CASH ❑ CHECk❑ <br /> sr # <br /> ADDRES. ADDRESS CUSTOMER CODE NO. <br /> CITE' 'Sj'ATE ZIP CO crrI, STATE. ZIP CO PO a <br /> .av a(,mc) <br /> PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. <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 /> Lased 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) fool Fxr <br /> Oil&Water,Non-RCRA Hazardous Waste.Liquid CAMI Gal <br /> Waste Solids and Sludges Gal <br /> Wash-out Each <br /> Drained I sed Oil Filters Drum <br /> Non-RCRA Hazardous Waste Solids(oily debris) CA 223 Drum <br /> Empty Drums Drum <br /> Transportation Mrs. <br /> Other: <br /> Other: <br /> Other: <br /> Other <br /> Other: <br /> Other: <br /> Other: <br /> Other: <br /> TEST PASS FAII,❑ PPM O Test i— <br /> ❑Collection Station ❑bicultural Source a tfO 9 <br /> ❑Government Source Industrial Source 1 A L <br /> ❑Marine Source <br /> CHARGES � V <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 manifested to Evergreen facilities so long as it meets the <br /> EPA# CAD9808874118 approved acceptance criteria. <br /> AtA ) 0 C? x'11 <br /> D R ROUTE# 7"R SIGNATURE GENERATO 'S SIG TURF PRINT NAME <br />