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1w, 0 Bill of Lading/Invoice <br />a <br />V, Evergreen Environmental Services 7 3 <br />dedicated to the protection of the environment <br />09 <br />To schedule ae�pickup, call Send `payment �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 INFORMATInN <br />NAME <br />CA 221 <br />NAME <br />—� <br />C. -ASH ❑ CHECh❑ <br />ADDRESS <br />- -- - - <br />ADDRESS <br />CUSTOMER CODE NO. <br />/IS 'P / <br />9157 <br />.S' � <br />CITY <br />A'rE CO <br />CITY <br />STATE ZIP CO <br />PO 9 <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993 III (Oil contaminated with halogens) <br />�S^' +ZIP <br />Gal <br />PHONE NO. <br />PHONE NO. <br />CA221 <br />PROFILE NO. <br />CUSTOMER EPA ID NO - <br />Gal <br />Waste Solids and Sludges <br />( <br />PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br />CODE NUMBER (Fns Time Of Rrrvirr (lnlvl <br />Used oil, Non- RA Hazardous Lubricating <br />Waste, Liquid Industrial <br />CA 221 <br />(Tal <br />- -- - - <br />CA 221 <br />Gal <br />Used Automotive Antifreeze, Non-RCRA Hazardous <br />Waste, Liquid <br />CA 134 <br />(Tal <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993 III (Oil contaminated with halogens) <br />CA 221 <br />RX)l Tom <br />Gal <br />Oil & Water, Non-RCRA I]azardous Waste. Liquid <br />CA221 <br />Gal <br />Waste Solids and Sludges <br />Gal <br />— -- <br />Wash-out <br />Each <br />Drained I ised Oil Filters <br />Drum S <br />1� <br />Non-RCRA Hazardous Waste Solids (oily debris) <br />CA 223 <br />Drum <br />Empty Drums <br />Drum <br />Transportation <br />tits. <br />Other: <br />Other: <br />- <br />Other:---- <br />-- <br />Other <br />Other: <br />Other: <br />Other: <br />— <br />— <br />(ther: <br />]'EST PASS ❑ FAIL <br />❑ PPM rest <br />❑ Collection Station ❑ Agricultural Source <br />❑ Goverment Source ❑ Industrial Source <br />❑ Marine Source <br />TOTAL <br />(.11 A R G E 5 /-5 <br />"YOU WILL ALSO RECEIVE A COMPO TER <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 />Evergreenr <br />•::f' Smith Avenue <br />A 94560 <br />EPA# r .. <br />7418 <br />DRIVER _ ROUTE 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 />G E "'R'S SIGNATURE PRINT NAME <br />