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-EVERGREEN <br />11 PVA NVIRE ® L <br />SERVICES <br />6880 SMITH AVE., NEWARK, CA 94560 <br />(800) 972-5284 EPA ID# CAD 98069S761 <br />JOB LOCATION <br />A DIVISION OF CALIFORNIA OIL RECYCLERS, INC. <br />.6 OF <br />NVOICE j • <br />DATE <br />BILLING INFORMATION I �?n - 9 <br />C <br />NAME <br />NAME <br />CASH ❑ CHECK# <br />NON-RCRA HAZARDOUS <br />WASTE LIQUID <br />P[4cj�ic o4ST oucc2s <br />UN9189 (OIL & WATER) <br />PO # <br />S <br />OTHER: — 5 6 4(- DQ'am OF 62E4SL SLt)CC 32CJo507 43S6 00 3Sd oa <br />DRAINED USED OIL FILTERS i <br />CRUSHED UNCRUSHED I EMPTY <br />—J <br />T <br />ADDRESS <br />ADDRESS <br />CUSTOMER NO. <br />qql S®. S`f6CIGToN ST <br />Coos' <br />CITY STATE ZIP CO <br />CITY STATE ZIP CO <br />PHONE NO. <br />Lob", Cl gszy? <br />c .2�i )33Y•3z <br />PLEASE PAY FROM TYIS 1VV*ICF *1 ?.. <br />PRODUCT MANIFEST # GALLONS PRICE AMOUNT <br />USED OIL, NON-RCRA HAZARDOUS WASTE, <br />COMBUSTIBLE LIQUID, NA1270 <br />LUBRICATING <br />INDUSTRIAL <br />NON-RCRA HAZARDOUS <br />WASTE LIQUID <br />UN1142 (AUTOMOTIVE ANTIFREEZE) <br />UN9189 (OIL & WATER) <br />WASTE PETROLEUM OIL NOS COMBUSTIBLE LIQUID NA1270 <br />(GREATER THAN 1000 ppm HALOGENS) <br />TEST PASS ❑ FAA. ❑ PPM <br />OTHER: — 5 6 4(- DQ'am OF 62E4SL SLt)CC 32CJo507 43S6 00 3Sd oa <br />DRAINED USED OIL FILTERS i <br />CRUSHED UNCRUSHED I EMPTY <br />—J <br />TSDF EVERGREEN OIL, INC. (510) 795-4400 1 certify that the information and amounts shown above are true and correct TOTAL ® 60 <br />6880 Smith Avenue EPA ID# CAD 9808$7418 and that the used oil provided to Evergreen Environmental Services meets the emu ®//�m Cpm <br />definition of used oil pursuant to California Health tE Safety Code, Section BSIlA1IG S <br />Newark, California 94560 25250.1, unless otherwise noted. This further serves as notification that the <br />above waste is banned from land disposal pursuant to Section 66268.7(10) of <br />Title 22. I also acknowledge that 1 have read and agree to the terms and <br />conditions set forth on the reverse side of this form. <br />DRIVER ROUTE # DRIVER SIGNATURE <br />Z v`/ <br />GENERATOR'S SI ORE' <br />• _ x ..>. .� � .,.;� �'«,. :max � a ,,� i+r?,- s � �r � � Xr: �S 1 '2: <br />IMEC 1 1993 <br />