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SBill of Ladingilnvoice <br />Evergreen Environmental Services <br />WA <br />787909 <br />dedicated to the protection of the environment <br />To schedule a pickup, call Send payinent to,, Sales Order <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 />Date --- <br />JOB LOCATION BILLING INFORMATION <br />NAME <br />CA 221 cl�" <br />NAME <br />Gsl <br />CASH ❑ CHECK❑ <br />i CA 221 <br />Gal <br /># <br />ADDR S <br />Used Automotive Antifreeze, Non-RCRA Hazardous <br />Waste, Liquid <br />ADDRESS <br />CUSTOMER CODE NO. <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993 ILL (Oil contaminated with halogens) <br />CA 221 <br />RDI,gm <br />CITY <br />'STATE ZIP CO <br />CITY <br />STATE, "ZIP CO <br />PO 9 <br />Waste Solids and Sludges <br />PHONE N. <br />PHONE NO. <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />Each <br />Drained Used Oil Filters <br />PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br />CODE NUMBER I ( For Time Of Service Only) <br />Used oil, Non-RCRA Hazardous Lubricating <br />Waste, Liquid Industrial <br />CA 221 cl�" <br />Gsl <br />i CA 221 <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 ILL (Oil contaminated with halogens) <br />CA 221 <br />RDI,gm <br />Gal <br />Oil & Water, Non-RCRA Hazardous Waste. Liquid <br />CA221 <br />Waste Solids and Sludges <br />Gal <br />Wash-out <br />Each <br />Drained Used Oil Filters <br />Drum <br />Non-RCRA Hazardous Waste Solids (oily debris) <br />CA 223 <br />Drum <br />Empty Drums <br />Drum <br />Transportation <br />Hrs. <br />Other: <br />Other: <br />Other: <br />— — — <br />Other <br />_ v <br />Other- <br />therOther <br />Other <br />Other: <br />_ <br />Other: <br />TEST PASS FAIL, ❑ PPM <br />Collection Station ❑ Agricultural Source <br />Government Source ❑ Industrial Source <br />❑ Marine Source <br />TOTAL <br />CIIARGEsrd <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 />EvergreenTSDF • <br />.:1 Smith Avenue <br />Newark, CA 94560 <br />CAD980887418 <br />fDRfVER ROUTE #/P R 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 />h <br />GENERATOICS SIGNATURE PRINT NAME <br />