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Bill of Lading/Invoice <br />Evergreen Environmental Services <br />786171 <br />dedicated to the protection of the environment <br />To schedule a pickup, call Send payment to: Sales Order # t/ 4"eo-z, <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 Date <br />JOB LOCATION BILLING INFORMATION <br />NAE <br />NAME <br />CASH ❑ CHECK[] <br />QUANTITY <br />UNITS PRICE AMOUNT <br />( For Time Of Service Only) <br />Used oil, Non- CRA H dous Lubricating <br />Waste, Liquid Industrial <br />ADDRESS <br />ADDRESS <br />CUSTOMER CODE NO. <br />Gal 16 <br />Gal <br />%b C Uu Z. <br />CITY STATE ZIP CO <br />CITY STATE ZIP CO <br />PO 9 <br />Gal <br />RQ Waste Combustible Liquid, N.O.S. NA <br />1993 III (Oil contaminated with halogens) <br />PHONE NO. <br />PHONE NO. <br />PROFILE NO. <br />CUSTOMER EPA ID NO. <br />— i3 <br />Oil & Water, Non-RCRA Hazardous Waste, Liquid <br />CA221 <br />PRODUCT <br />WASTE <br />CODE <br />MANIFEST <br />NUMBER <br />QUANTITY <br />UNITS PRICE AMOUNT <br />( For Time Of Service Only) <br />Used oil, Non- CRA H dous Lubricating <br />Waste, Liquid Industrial <br />CA 221 <br />CA 221 <br />9 <br />Gal 16 <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 III (Oil contaminated with halogens) <br />CA 221 <br />R014002 <br />Gal <br />Oil & Water, Non-RCRA Hazardous Waste, Liquid <br />CA221 <br />Gal <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 />• <br />Other: <br />Other: <br />I o4 lou, <br />1-1 - Cj • 00 <br />Other: <br />o <br />I V l S <br />Other: <br />Other: <br />Other: <br />Other: <br />Other: <br />TEST �,. PASS El <br />FAIL., ❑ <br />G� PPM <br />est <br />1 ILL, <br />Collection Station ❑ Agricultural Source <br />El Government Source [I'T®'T <br />Industrial Source <br />❑ Marine Source <br />1 1 LCL <br />TOTAL <br />C I I A R G E S <br />/. <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 />TSDF: Evergreen Oil, Inc. <br />6880 Smith Avenue <br />Newark, CA 94560 <br />EPA# CAD980887418 <br />ROUTE # DRIVER) <br />Accounting Office 949-757-7770 <br />ft0=3 <br />I hereby certify that a formation in this an yN attached documents <br />contains true and accurate JRte 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. /,),-7 <br />'S SIGMA <br />NAME <br />