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� t <br /> Evergreen Envirgnmental Services <br /> dedicated to the protection of the environment Bill of Lading/ Invoice <br /> To schedule a picku ,call Send payment to: <br /> 800-972-52 4 Evergreen INVOICE 669714 <br /> 6880 Smith Ave.,Newark, CA EPA#CAD982 13262 P.O.Box 49065 _ <br /> 16540 S.San Pedro St.,Carson,CA EPA#C /3982413262 San Jose,CA 95161-9065 Date f—Ir—b III C� ( <br /> JOB LOCATION BILLING INFORMATION <br /> NAME NAME CASH ❑ CHECI;❑ <br /> ./_ # <br /> ,-)DRESS ADDRESS CUSTOMER CODE.NO. <br /> O <br /> CITY STATE ZIP CO CITY STATE ZIP CO PO# <br /> PHONE N01 PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. <br /> ( 3!3--2Z� ) <br /> PRODUCT G WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER <br /> t used oil,Non-RCRA H s Lubr eating CA 221 ?77-0717o O Gal <br /> Waste,Liquid hidiv trial CA 221 Gal <br /> I'sed Automotive Antifiveze,Non-RCRA HazArdo is CA 134 Gal <br /> Waste,Liquid <br /> RQ Waste Combustible Liquid,N.O.S.NA CA 221 Gal <br /> 1993 Ill(Oil contaminated with halogens) 101 (w <br /> Oil 8c Water,Non-RCRA Hazardous Waste,Liquid CA221 Gal <br /> Waste Solids and Sludges Gal <br /> Wash-out Each <br /> Drained Used Oil Filters Ileum <br /> Nun-RCRA hazardous Waste Solids(oily dentis) CA 223 Drwri <br /> Empty Ihunts Drunt <br /> Transportation llrs. <br /> Other: <br /> Other: <br /> Other- <br /> Other <br /> thert Other <br /> Other: <br /> Other: <br /> Other: <br /> Other: <br /> TES PAS FAIL❑ I'PM Test <br /> Collection Station ❑Agricultural Source <br /> ❑GoWT[Unenl Source [I Industrial Source NET 7 DAYS '00P <br /> T OTA L <br /> El Marine Source <br /> (CHARGE - <br /> Accounting Office 510-795-4 0 P e Pay From This Invoice <br /> TSDF: Evergreen bit, Inc. I hereby uxtity that all information submitted in this and all attached documents <br /> 6880 Smith AvenuE contaun true and accurate descriptions of the waste. All relevant information <br /> - regarding known or suspected hazards associated with the waste has been disclosed. <br /> Newark, CA 94560 Tim further serves as notiticabon that the above liquid wastes arc banned from land <br /> EPA# CAD980887 18 disposal pursuant to Title 22 Section 66268.7(ax10). I also ackrwwledge that I have <br /> read and agree to the terins on the reverse side of this form. <br /> '1L 7C>3V I CN (o c r✓➢J7 <br /> RIVER ROUTE# DR IGNATURE �GENERATOR'S SIGNATURE PRINT NAME <br />