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C <br />Evergreen Environmental Services <br />dedicoted to the protection of the environment <br />To schedule a pickup, call Send payment to: <br />800-972-5284 Evergreen <br />6M Smilh .Ave., Newark, CA EPA# CA0982413262 P.Q. sox 49065 <br />16540 S. San Pedro St., Carson, CA EPA# CADS82413262 San Jose, CA 95161-9065 <br />RVI I.iwr_ 1N nDUAT1Fnw <br />1Lading <br />1p <br />732994 <br />Date ",�___%?% _X <br />— <br />NAME <br />CODE NLTM13ER <br />NAME <br />rr <br />CASH ❑ CHEC ' <br />L a <br /># 7 Lq #i <br />ADDRESS I <br />WNW" form, <br />ADDRESS <br />CUSTOMER CODE NO. <br />9� <br />cr1y <br />ATE ZIP CO <br />CITY <br />STATE ZIP CO <br />PO # <br />S <br />PHONE NO. <br />PHONE NO. <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />200h -Wf % Z. <br />Z <br />i I <br />I jab <br />If/M <br />- '�aen�,IAv, <br />CODE NLTM13ER <br />For Time Of Service Only) <br />rr <br />i <br />WNW" form, <br />• ... <br />/ice/����� <br />:,PPM <br />IN <br />G ..Statim •_ <br />■ ■ <br />w .„:, . <br />i <br />r fA4 I” A 9 '111171 1411j, <br />1 1' <br />1.1131 IV, I Of i 41VA 111"I in <br /># 1 t <br />r e <br />#.:• Smith Avenue <br />Newark, CA .1 <br />CADS80887418 <br />Accounting vmce U4V-i5 -1 0 <br />I hereby certify that all information in this and all attached documents <br />contains tree and accurate descriptions of the waste. All relevant information regard- <br />ing known or suspected hazards associated with the waste has been disclosed. <br />I also acknowledge that I have read and agree to the terms on the reverse side <br />of this form. <br />Pursuant to Title 22,Section 66264.12, Evergreen Oil. Inc, Evergreen <br />Environmental Services, has the appropriate permits for and will accept <br />the wastes manifested to Evergreen facilities so long as it mccu the <br />approved acceptance criteria. <br />