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#.vergreen Environmental Services <br />dedicated to the protection of the environment <br />To Schedule a pickup, call Send payment to: <br />800-972-5284 Evergreen <br />GM &nith Ave., Newark. CA EPA# CAD982413262 P.O. Box 49065 <br />16540 S. San Peft SL, Carson, CA EPA# CAD982413262 San Jose, CA 95161-9065 <br />RI1.1.IN[3 1NMRMATInN <br />C <br />91:1 <br />® 22� I <br />!)ate <br />NAM& <br />WASTE <br />CODE <br />MANIFEST <br />NUMBER <br />NAME — --- <br />----- <br />CASH ❑ CHECK <br />1_6 <br />.'\DDRESS <br /># <br />CUSTOMER CODE NO. <br />ADDRESS <br />0 • <br />1 <br />C.t7 <br />CITY <br />-ATE "LIP <br />CO <br />CITY <br />S'I'Xl'E 'LIP CO <br />PO a <br />PHONE NO. <br />PHONE NO. <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />fjfj!k-7cnAoL9® <br />PRODUCT <br />WASTE <br />CODE <br />MANIFEST <br />NUMBER <br />QUANTITV UNITS PRICE AMOUNT <br />For Time Of Service Only) <br />1993 M (Oil cantasainated with halogens) <br />TOTAL <br />CIIARGES,mi <br />"THIS IS NOT AN INVOICE; YOU WILL <br />RECEIVE AN INVOICE FROM OUR <br />ACCOUNTING DEPT. PAYMENT AT TIME OF <br />SERVICE WILL ALSO BE NOTED ON INVOICE". <br />TSDF: Evergreen Oil, Inc. <br />Smith Avenue <br />Newark, CA 94560 <br />EPA# CAD980887418 <br />Accounting Office 949-757-7770 <br />ROUTE # DRWER SIGNATURE <br />I hereby certify that all information in this and all att shed documents <br />contains true and accurate descriptions of the waste. All relevant infonnauon 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 66261.12, 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 meets the <br />approved acre Lance c leria. <br />G RATOR'S SIGNATURE PRINT NAME <br />