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dAVAI <br />Evergreen Envirommental Services <br />to Awprweetion ql aw environmew <br />TO s pickup, Call Send payment to: <br />800-972-5284 Ever <br />4W 1110011h Ave� Newark, CA EPA6 CA0982413262 P.O. Box 49065 <br />We 8• am Pawe SL, CA EPA+I CAOM413N2 San Jose, CA 95161-9065 <br />BILLING INFORMATION <br />C <br />1:1111 no I <br />• <br />EWA <br />y <br />CODE <br />, <br />Mr <br />A" 0 934pr7m <br />u <br />PHONE NO. <br />PROFILE NO. <br />i •. <br />�J is �' <br />,_. • <br />CODE <br />QUANTITYWASTE MANIFEST AMOUNT <br />NUMBER For Tinn Of Service Only) <br />Mr <br />A" 0 934pr7m <br />u <br />OWN <br />• <br />11 a 1114K1 I <br />I <br />I hereby certify that all information in this and all attached documents <br />contains true and accurate descriptions of the waste. All relevant informum reSard- <br />ing known or suspected hazards associated with the waste has Oeao disciosed. <br />1 also acknowledge shat 1 have read and agree to the tams an the reverse side <br />of this form. • <br />Pmmt to Title 22.Section 66264.12. EveMm Oil. Inc, Evetrw <br />Environawatal Services. has the appropriate permits for and will accept <br />the wastes inanifeaW to Evergreen facilities ro IMS as it mom the <br />approved AcccPance criteria. <br />e I� <br />ROUTE# DRIVERPIGNATURE GB T ­0'S SIGNA PRINT <br />