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aectrcated to the protection of the environment <br /> • � To schedule a Send pa}mcnt to: �• <br /> Sales Order#56��a2_75 <br /> 800-97 O 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 <br /> Date <br /> JOB LOCATION BILLING INFORMATION <br /> NA4E <br /> NAME U CASH ❑ CHECK❑ <br /> ADDRESS � # <br /> ADDRESS <br /> M CUSTOMER CODE NO. <br /> AI I S ATE ZIP 7 CO CITY' STATE ZIP CO PO# <br /> HONE NO. J a c' <br /> PHONE NO. I PROFILE NO. CUSTOMER EPA ID NO. <br /> ( —44�i� <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> Used oil,Non-RCR'1 Hazardous Lubricating CODE NUMBER (For Time Of Service Only) <br /> CA 22] <br /> Gal <br /> Waste,Liquid Industrial CA 221 <br /> Gal G �� <br /> Used Automotive Antifreeze,Non- RA Hazardous CA 134 <br /> Waste,Liquid Gal <br /> RQ Waste Combustible Liquid,N.O.S.NA CA 221 <br /> 1993 111(Oil contaminated with halogens) Gal <br /> laDl.'It702 <br /> Oil&Water,Non-RCRA Hazardous Waste.Liquid CA221 <br /> Gal <br /> Waste Solids and Sludges <br /> Wash-out <br /> Gal <br /> Drained Used Oil Filters Each <br /> Non-RCRA Hazardous Waste Solids(oily debris) CA 223 Drum <br /> Empty Drums Drum <br /> Transportation <br /> Drum <br /> Other: <br /> Hrs. <br /> Other: <br /> Other: <br /> Other: <br /> Other: <br /> Other: <br /> Other: <br /> Other: <br /> TEST PASS FAIL <br /> ❑ PPM Test <br /> ❑Collection Station ❑ -icultural Source <br /> ❑Govemment Source Industria)Source TOTAL❑Marine Source I 1 O <br /> CII �RGES Tam <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 /> TSDF: Evergreen Oil, Inc. I also acknowledge that I have read and agree to the terms on the reverse side <br /> 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# CAD980887418 <br /> approved acceptance criteria. <br /> a <br /> R ROUTE# D SIGNA URE GENERATOR'S SIGNATURE <br /> PRINT NAME <br />