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Bill of Lading/Invoice <br /> Evergreen Falivironmental Services 793365 <br /> dedicated to the protection of the environment <br /> TO schedule a ickLIP, call Send payment to: Sales Order# <br /> 800-972 5284 Evergreen <br /> 6860 Smith Ave.,Newark, CA EPA#C D982413262 P.O.Box 49065 <br /> 16540 S.San Pedro St.,Carson,CA EP #CAD982413262 San Jose,CA 95161-9065 <br /> Date <br /> JOB LOCATION <br /> NAME BILLING INFORMATION <br /> NAME CASH ❑ CHF,CK❑ <br /> ADDRESS ADDRESS <br /> y <br /> CUSTOMER CODF,NO. <br /> CM, STA E ZIP CO CITti' STATE ZIP CO PO# <br /> HON � .S 7 <br /> PHONE NO. PROFILE No. CUSTOMER EPA ID NO. <br /> tN . <br /> Z <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> 1� CODE NUMBER (For Time Of Service Only) <br /> Used oil,Non-RCRA l$zardous. ubricatmg CA 221 g 3 Gal <br /> v <br /> Waste.Liquid tdusirial CA 221 Gal <br /> Used Automotive Antifreeze,Non- CRA Haz ous CA 134 Gal <br /> Waste,Li id <br /> RQ Waste Combustible Liquid,N.O.S.NA CA 221 Gal <br /> 1993111(Oil contaminated with halogens) R1t71,m <br /> Oil&Water;Non-RCRA Hazardous Waste,L uid CA221 Gal <br /> Waste Solids and Sludges Oat <br /> Wash-oEach <br /> Drained Used Oil Filters Drum <br /> Non-RCRA Hazardous Waste Solids(oily debri ) CA 223 Drum <br /> Empty Drums <br /> Ilium <br /> Transportation lira <br /> Other: <br /> Other: <br /> Other: <br /> Other <br /> Other: <br /> Other: <br /> Other: <br /> Other: <br /> TE P S FAIL. PPM est n <br /> Collection Station ❑Agricultural Source I TO 1 A <br /> ❑Govertanem Source ❑Industrial Source t'f <br /> ❑Marine Source C� <br /> CHARGE <br /> "YOU WILL ALSO RECEIVE A COMPLY ER Accounting Office 949- -7770 <br /> GENERATED INVOICE AND/OR <br /> STATEMENT FROM OUR ACCOUNTIN 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 leen disclosed. <br /> 1 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#CAD980887418 approved acceptance criteria. <br /> DRIVER OUTE# D SIGNATURE RATOR'S SIGNATURE PRINT NAME <br />