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FREMOUW ENVIRONMENTAL SeRVICES, INC. <br />Send Payment to: Phone: 800-559-3274 EPA ID # CAR000171017 <br />P.O. Box 2875 Phone: 707-448-3700 U.S.D.O.T. # 1484667 INVOICE # <br />Vacaville, Ca 95696-2875 Fax: 707-448-3499 D.T.S.C. # 3544 <br />www.hazwasteremoval.com CA # 274461 Date <br />SITE ADDRESS _ BILLING/MAILING ADDRESS <br />Customer Customer _ _ -- Y ` `% '- . <br />Phone <br />1(4 Ar11Tv <br />PRODUCT - SERVICE INFORMATION/PROPER SHIPPING DESCRIPTION <br />7 14 • 21 • 30 • 45 • 60 • 90 • 180 • 365 WAC <br />WASTE <br />CODE <br />MANIFEST NUMBER <br />QUANTITY <br />UNITS <br />PRICE <br />AMOUNT <br />Empty Drums Provide 0 Remove D 1 A 1 1 A2 5g ❑ 1 Og ❑ 15g ❑ 30g ❑ 55g ❑ S P F <br />Clor-D-Tect Q4000 Test Kit: Test ❑ Pass ❑ Fail ❑ Generator Knowledge ;O, PPM <br />Transportation Charges/Additional Truck Time/Additional Labor/ LAB Packing/Site Cleaning <br />Clean: Y N <br />Labels <br />Oil <br />A/F <br />UOF <br />Oily Debris <br />SERVICES REQUESTED BY <br />TAX <br />A ce t ': Ri ® <br />P. O. # TOTAL CHARGES: <br />GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, packed, marked, and <br />labeled, and are in all respects in proper condition for transport by highway according to applicable state and national government regulations. If I am a large quantity generator. I certify that I <br />have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically, practicable and that I have selected the practicable method <br />of treatment. storage, or disposal currently available to me which minimized the present and future threat to human health and the environment; OR. if I am a small quantity generator. I have made <br />a good faith effort to minimae my waste generation and select the best waste management method that is available to me and that I can afford. All used oil from the generator listed above <br />will be transported only to a facility permitted by the State of California to produce used oil into recycled of OR o facility that Is required to comply with Federal regulations applicable to the <br />management of used oil. All relevant information regarding known or suspected hazards associated with this waste has been disclosed. The customer agrees to pay reasonable costs and attorney <br />fees incurred in the collection of this obligation. Venue for u ses of this obligation shall be in Solana county. I declare under penaltyof pejury that the forgoing is true and correct. <br />DISPOSAL/RECYCLING FACILITY: C6119CtlOn Station Industrial Agriculture Govemment Marina Other I^d l0>ll wbrtoi°r^Q" <br />Name Generator's Signature Driver's Signature <br />I_herebv_certify that I have read_and have the authority to bind the above listed generator to the terms on the reverse side of this form. <br />State Law Requires that you keep this Receipt/Bill of Lading on file no less than 3 years. <br />