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J <br /> AS <br /> Evergreen Environmental Services <br /> dedicated to the protection of the environment Bill of Lading <br /> To schedule a pickup, call Send payment to: N° 781826 <br /> 800-972-5284 Evergreen <br /> 6880 Smith Ave.,Newark, CA EPA#CAD982413262 Y.O. Box 49065 _ <br /> 16540 S.San Pedro St.,Carson,CA EPA#CAD982413262 San Jose,CA 95161-9065 Date _Z c�(� Z->ou <br /> JOB LOCATION BILLING INFORMATION <br /> N NAME. C'ASII ElCIIF:CK[1 P7 <br /> o14 KoL— - /- / of I # <br /> ADDRF,SS ADDRI•:SS CUSTOMER CODE.NO. <br /> S <br /> 7 "� Gl�i� U /� // L. /,vlw <br /> CIT); STA'I E ZIP CO CITY STA E 7.11' CO PO N <br /> BONE N(L PHONE NO. I PROFILE NO. CUSTOMER EPA ID NO. <br /> /5 95� <br /> PRODUCT / WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> l'-v CODE NUMBER (For Time Of Service Only) <br /> Used oil,Non-RCRA Ilvardous Lubricating CA 221 fps �. 1 (;a] <br /> Waste,liquid Industrial CA 221 fV� V (Dal <br /> Used Automotive Antifreeze,Non-RCRA hazardous CA 134 Gal <br /> Waste,Uquid <br /> RQ Waste Combustible Liquid,N.O.S.NA CA 221 (Dal <br /> 1993111(Oil contaminated with halogens) Twill ID2 <br /> Oil&Water,Non-RCRA hazardous Waste,Liquid CA221 G81 <br /> Waste Solids and Sludges Gal <br /> Wash-out <br /> Each <br /> Drained I Ised Oil Filters Ilium <br /> Non-RCRA hazardous Waste Solids(oily debris) CA 223 Druin <br /> Empty Drums Drum <br /> Transportation I lrs <br /> Other: <br /> Other: <br /> Other: <br /> Other <br /> (Mhex: <br /> Other: <br /> Other: <br /> Other: <br /> TE - _ PASS FAIL❑ PPNI 1'es1 <br /> Collection.Station ❑Agricultural Source <br /> ❑Government Source ❑Industrial Source TOTAL <br /> ❑Marine Source <br /> C <br /> HARGES <br /> "THIS IS NOT AN INVOICE,; YOU WILL Accounting Office 949- <br /> RECEIVE AN INVOICE FROM OUR <br /> ACCOUNTING DEPT. PAYMENT ATTIME,OF I herebv certify that allin this- euached documents <br /> OIC contains true and accurate descriptions of the waste.All relevant infonnatioegard- <br /> SERVICE WILL ALSO BE NOTED ON INVing knoa n or suspected hazards ascmxiated with the waste has been disclosed. <br /> I alsn acknou ledge that I have read and agree to the terms on the reverse side <br /> SDF: Evergreen Oil, Inc. of this form. <br /> 6880 Smith Avenue Pursuant to Title 22,Section 66264.12.Evergreen Oil.Inc.Evergreen <br /> Newark, CA 94560 Environmental Services.has the appropriate pennits for and will accept <br /> the wastes manifested to Evergreen facilities so long as it meets the <br /> EPA# CAD980887418 approvWacceince criteria. <br /> RIVERROLITE# DRIVER SI :NATURE GEOR'S SIGNATURE PRINT NAME <br />