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Evergreen A DIVON OF CALIFORNIA OIL,RECYCLERS, INC. <br /> ,• � .. <br /> " Environmentalill Lain Invoice <br /> na payment to: <br /> Services Evergreen <br /> 6880 Smith Ave., Newark, CA 94560 <br /> P.O. Box 45987 k , <br /> (800) 972-5284 E>�n II)it CAD ���os0 a7( I San Francisco, CA 94145 $ <br /> DAT�j a x - <br /> JOB LOCATION BILLING INFORMATION P 7 e ` <br /> NAME NAM/E CASH CHECK# <br /> S 4 I & # <br /> TADDRESS p " ;! =,• -` ' ADDRESS CUSTri,,Np <br /> CITY STATE ZIP CO CITY STATE ✓ZIP CO J Py G <br /> .,/• .. .4�°�' •"3�C. r`� J '�Gr .5.:/ J"�• ...'9tJ/L'r'.&'.ti ,1 f / '�'�/ (, `„f, �� F� -OP L <br /> PRODUCT _ MANIFEST# GALLONS PRICEgj '; AMOUNT <br /> USED OIL, NON-RRA HAZARDOUS <br /> WASTE LIQUID LUBRICATING <br /> Gf f y' INDUSTRIAL_ Ga y <br /> r2 � <br /> NON-RCRA HAZARDOUS (AUTOMOTIVE ANTIFREEZE) <br /> WASTE LIQUID (OIL&WATER) = ' <br /> ASTE PETROLEUM OIL COMBUSTIBLE LIQUID UN1270 Illi • <br /> TEST PASS a FAIL ❑ PPM 77,77 <br /> OTHER: , <br /> CRUSHED UNCRUSHED EMPTY •rye <br /> DRAINED USED OIL FILTERS « <br /> _ i ceruiy ihat the information and amounts shown abode are true <br /> ___...,.._..,.._...e,_a.______.._;,. •„, r <br /> ecri <br /> e - t Bets dit:c o ;ed TOTAL�r� AgrICl.tural Source -1 Government SOUrG. a o n that the a eoil Provided to Evrgr En:rcn-F1 Collection Station CHARGES�..Irdustiai Sou,:e if oourc�� oo p_sant to <br /> Caldo rda health 3 Safety, <br /> - <br /> Code,Section 25250-t,unless other- r <br /> wisenoted This further servesasnotiharhonthattheabovewaste <br /> ti-Vr r iC HC E N OIL!NC (5t 0) 79 4400 banned from land disposal r ers im to Section 66268-7(10)of PLEASE PAY�.� ��THIS INVOICE <br /> br'3,,, ,itnA r ,.e EPA IDpCAP 03b;418 T 22 lasO CKIICaed � r aveadandagreelothelerms <br /> n+..ee..n.pwe ,.�.....s..� <br /> Nt�'W BfK Cd'(ornia 94`60 ,d sgndil o ,et forth on the eders� rte of This form. <br /> .d� t d ,�: �.���''�•-.• <br /> 5 <br /> DRIVER ROUTE# DRIVER SIGNATURE GENERATOR'S SIGNATURE <br /> �r <br /> A' <br /> a <br />