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Evergreen Environmental Services <br />dedicated t <br />• the protection of the environment <br />To schedule a pickup, call send payment to: <br />800-972-5284 Evergreen <br />68W Saft Ave., Newark, CA EPA# CAD982413262 P.O. Box 49065 <br />16640 S. San Pedro SL, Carson, CA EPA# CAD982413262 San Jose, CA 95161-9065 <br />Rio] 1-7w!r <br />N Ahi.i.INV- 11NVf%RMAT1Fnrd <br />Bill of LadingAnvoice <br />787579 <br />Sales Order # <br />Date 10 � fZ st <br />E e <br />WASTE <br />CODE <br />CASH ❑ CHECKff- <br />14,/!(AVI <br />Used $ Noa-RCRA " " dour Lubricating <br />Wauts. Liquid Industrial <br /># <br />ADDRESS ADDRESS <br />Gal <br />Gal <br />CUSTOMER CODE NO. <br />:? <br />CA 134 <br />Gal <br />CSC? <br />CITY STATE ZIP CO CITY <br />STATE ZIP CO <br /># <br /><-.9, % S7- Q15 <br />Oil & Walcr, NowRCRA Hazardous Wage, liquid <br />W <br />QU2j— <br />PHONE NO. PHONE NO. <br />r7Gal <br />Gal <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />PRODUCT P/ <br />s r—Z <br />WASTE <br />CODE <br />MANIFEST <br />NUMBER <br />QUANTITY UNITS PRICE AMOUNT <br />( For Time Of Service Only) <br />Used $ Noa-RCRA " " dour Lubricating <br />Wauts. Liquid Industrial <br />CA 221 <br />CA 221 <br />n;' <br />Gal <br />Gal <br />Used Automotive Antif ame, Non-RCRA Hazardous <br />Wave, " uid <br />CA 134 <br />Gal <br />RQ Waste ble Liquid. N.O.S. NA <br />1993111(Oil contaminated with halogens) <br />CA 221 <br />HIDI4UM <br />Gal <br />Oil & Walcr, NowRCRA Hazardous Wage, liquid <br />W <br />QU2j— <br />r7Gal <br />Gal <br />Wash-out <br />radn <br />DrameduaddoilFilters <br />Drum <br />NQwRCRA Hazardous Waste Solids (oily debris) <br />CA 223 <br />Drum <br />EmptYDrums <br />Drum <br />Tr on <br />lits <br />alter. <br />Other- <br />aha- <br />aha: <br />aba: <br />PASS <br />FAIL ❑ <br />PPM <br />T <br />0 collection Station 13 <br />❑ cav ❑ sourceral <br />® Marino somme <br />TOTAL <br />CHARGES <br />"YOU WILL ALSO RECEIVE A COMPUTER <br />GENERATED INVOICE AND/OR <br />STATEMENT FROM OUR ACCOUNTING OFFICE. <br />PAYMENT AT TIME OF SERVICE WILL <br />ALSO BE NOTED ON INVOICE". <br />M <br />Accounting Office 949757-7770 <br />Vaef <br />,,..,,,,.b.-1 _, <br />I hereby certify that all information in this and all attached documents <br />contains true 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 erns 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 meets the <br />approved acceptance criteria. <br />