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2011-Feb-11 02:10 PM GSW AG 209-'—�-8867 40/42 <br /> Evergreen En 'ronmental Services ` �Z73� <br /> 116 <br /> dedicated to the protection of the environment Bill of Lading <br /> To schedule a pickup, Cell ;.;r ntl i";.)alcill 1, No- 5 5 4 6 2 <br /> 800-972- 284 Evergtson <br /> 8890 Smith Ave.,Neweric, CA EPA#CAD 92413262 P.O. Box 49063 <br /> 18540 S.San Pedro St.,Caraon,CA EPAO CADS82413282 San lose,CA 95161-9065 ihtc 7- <br /> 300 <br /> JOA LOCATION BILLING INt=ORMATION <br /> N NAME CASH CHECKO <br /> �,- h-5W �C art <br /> N RE9S ADORES <br /> � ,�' c s•r01�l1:R Cont=No. <br /> /L J. �V1:✓X I U d O <br /> C STATE P CO Crry STATE 7,1P Co PO q <br /> V <br /> PHONF 140. PHONE NO, PIZOFIL13 N0. CUSTOMER EPA ID N0. <br /> PRODUCT , WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> `t! -J CODE NUMBER (For Time Of Service Only) <br /> (teed oil,N H dou. 1.ibrieadng CA 221 U v 1 <br /> Wase.Liquid Ir dustrial CA 221 (lal <br /> Used AutonuAivc Ardi&=a,Nnn-RCRA Hm-dow% CA 134 Gel <br /> W*AC6 Li id <br /> RQ Waste Combustible Uquld,N.O.S.NA CA 221 Gal <br /> 1993 m(Oil contaminated Wlth halogens) FOOI,4CO2 <br /> NI&Water,Non-RCRA Hazu&ua Wasto.Li id CA221 pal <br /> Warta Solids and Shtdgm Gal <br /> WARF-Md 1ACh <br /> brined(lied Oil Fitton Drum <br /> Non-RCRA fiawdous Waste Solids(oily do a) CA 223 Drum <br /> nKy DnuT* Drum <br /> Trurponatim Hrv. <br /> Other. <br /> Othr: <br /> Other <br /> [kFxr <br /> O)tbdr <br /> Other. <br /> Other: <br /> otba,. <br /> PSC LOJ FAA,0 PPM Tess �+ v� <br /> Mom 1:1 Agriculturid Source <br /> 00ovoiteocidS x 13Indlmiiil6ourte '!'O 3 AL <br /> egS� <br /> THIS IS NOT AN INVOICE( YOU WILL Accounting Office 9757.7770 <br /> KECEIVE AN INVOICE FROM OUR <br /> ACCOVNTING DEPT. PAYMENT T TIME OF 1 horeby cenity that nnedon In this I erta 11 documenu <br /> SERVICE WILL ALSO BE NOTED ON INVOICE". contains true and accurate desen n 0 the waste.All relevant Information regard- <br /> ing known Or Suspected halwilt associated with the Waste hat been disclosed. <br /> I also acknowledge that I have read and agree to the terms on the rcveru side <br /> TSDF: Evergreen Oil, Inc. of tine form. <br /> 6880 Smith Avenue) Punuarnt to Title 22,Section 66264.17.Evergreen Oil,Inc,Evngrean <br /> Newark, CA 8456 Environmenuil Services•has the appropriate permlts rer and%vIll secepi <br /> the wastet manlrested to Evergreen facillties to long as it meeu the <br /> EPA#CAD980887 18 approved acceptance criteria. <br /> ROUTE RIVE SIGNATURE GENE OR'S siGNA7URE PRINT NAMZ <br />