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Evergreen 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 />6880 Smith Ave., Newark, CA EPA# CAD982413262 P.O. Box 49065 <br />16540 S. San Pedro St., Carson, CA EPA# CAD982413262 San Jose, CA 95161-9065 <br />JOB LOCATION <br />BILLING INFORMATION <br />10 Bill of LadingAnvoice <br />792831 <br />Sales Order # �7 <br />Date .`61�7 --- <br />N <br />�ff <br />NAME <br />CASH EICHECK❑ <br />. <br />O v. 0 J4-t'Jd <br />UNITS PRICE AMOUNT <br />( For Time Of Service Only) <br /># <br />\Dl U�$S A� <br />ADDRESS L? <br />/f I& <br />CUTG O ODE NO. <br />J%-' -TA <br />CITY STATE ZTP CO <br />CITY CO <br />PO # <br />Gal <br />PHONE NO. <br />PHONE NO. <br />PRO <br />CUSTOMER EPA ID NO. <br />�* <br />) <br />I <br />PRODUCT <br />WASTE <br />CODE <br />MANIFEST <br />NUMBER <br />QUANTITY <br />UNITS PRICE AMOUNT <br />( For Time Of Service Only) <br />Used oil, Non-RCRA Hazardous Lubricating <br />Waste, Liquid Industrial <br />CA 221 <br />CA 221 <br />Gal <br />Gal <br />Used Automotive Antifreeze, Non-RCRA Hazardous <br />Waste, Liquid <br />CA 134 <br />Gal <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993 III (Oil contaminated with halogens) <br />CA 221 <br />F001/1M <br />Gal <br />Oil & Water, Non-RCRA Hazardous Waste. Liquid <br />CA221 <br />Gal <br />Waste Solids mid Sludges <br />Gal <br />Wash-out <br />Each <br />Drained Used Oil Filters <br />Non-RCRA Hazardous Waste Solids (oily debris) <br />CA 223 <br />rn <br />Empty Drums <br />Drum <br />Transportation <br />Imo• <br />Other: <br />Other: <br />Other: <br />Other <br />AL <br />Other: <br />IDA= <br />Other: <br />(0, <br />Other: <br />�- <br />Other: <br />TEST PASS ❑ <br />FAIL ❑ <br />PPM <br />Test <br />❑ Collection Station ❑ Agricultural Source <br />❑ Government Source El Industrial Source <br />❑ Marine Source <br />TOT A i <br />1 1 t1 L ^ <br />TOTAL <br />C i 7 A 1' !'r T Cr <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 />Accounting Office 949-757-7770 <br />TSDF: Evergreen Oil, Inc. <br />6880 Smith Avenue <br />Newark, CA 94560 <br />1 EPA# CAD980887418 <br />DIUVER ROUTE # DRIVER SIGNATURE <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 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 meets the <br />approved acceptance criteria. <br />i' •`Y1' 1` J <br />