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2011-Feb-11 02:10 PM DSW AG 209-?" '-8867 42/42 <br /> Bill of I,adingflnvoice <br /> Evergreen Envi> onmental Services 06806 <br /> dedicated to the protection of the environment <br /> To schedule a piCkrJp, Call Sales Order# � <br /> 800-972-5?84 Evergreen <br /> Box 490b5 <br /> 6880 Smith Ave.,Newark, CA EPA4 CA088�R413252 P.O.BoBo 9 9065 065 f <br /> 16540 S,San Pedro St..Carson,CA EPA#CrA0982413262 San Jose, <br /> Date `� - <br /> JOB LOCATION BILLING INFORMATION <br /> R NANIR CASIl C[iPCK❑ <br /> �✓ / # <br /> ,1DURESB ADDRESS CU UhIER CUuE NO. <br /> 50-z L2 <br /> C fT1 5TA'1'E LIP C[) CITY STATE 'LIP CO PD 0 <br /> _ r <br /> PHONE NO. <br /> PHONE NO. PROFILE NO. CUSTOMER SPA m NO. <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CORE I•iUMB$R (For Time Of Service Only) <br /> I Tmd oil,Non-RCRA II ous T hricating CA 221 C}al f ( 7 <br /> Waste,','quid <br /> In •ai CA 221 Gel <br /> Used Automotive Antifreeze.Non-RCRA Naze us CA 134 <br /> Gal <br /> Waste in id Gal <br /> RQ Waste Combustible liquid,N.O,S.NA CA 121 <br /> t493111(oil contaminated with halogens) P001 Gal <br /> (>;I water.Nrm-RCRA Hazardous Wnsto.Liquid t 1 <br /> Gel <br /> Wita¢e tiotid..�d studans <br /> Each <br /> Wes"c4" <br /> Drum <br /> Tkained I Ised Oil F'ihers <br /> Nnn-RCRA hazardous Waste solids(oily dab ) CA 223 Dtttm <br /> Ilium <br /> r,nVty Druma <br /> Transportation <br /> (.)that <br /> Other. <br /> Other: <br /> Other: <br /> t hhtT'. <br /> (Ahher: <br /> C*cr <br /> Other: <br /> TF.S' P l9S PAn. �•7�► PPM <br /> Collection Station Agricultural sour e L757-7770 <br /> TA 1� <br /> ❑Government Source ❑industrial Source . <br /> Marino 6oumv CHARGE'S <br /> -,You WILL ALSO REC LIVII A COMMUTER ACCO1Jilting Office 94GENERATED INVOICE AND/ORS'fATFNII:NTFROM OUR ACCOLINT�N0 OFFICE:. I hereby certify thaand all c ed documents <br /> PAYMENT-ATTIME OF SERVICE WI .1contains true and acante.All relevant information regard- <br /> Al,5U E3E NOTE[)ON IN VOICIi"• ing known or suspected beards associated with the waste hes been disclosed. <br /> I aim acknowledge that 1 have read and agree to the terms an the reverse aide <br /> SDF: Evergreen 011, Inca of this form. <br /> n Pursuant to Title 22,5ec ion 66264.14,Evergreen Oil,Inc.Evergreen <br /> 6880 Smith Aveni <br /> flnvironmental Services,has the appropriate permits for and will accept <br /> Newark, CA 94560 the wastes manifested to Evergreen facilities to long as it meets the <br /> EPA#CAD980887413 approved Criteria. <br /> r <br /> RIVER <br /> PRINT NAME <br /> ROUTE# DR R S NATURE G T 'S SIGNATURE <br />