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OD
<br /> rECHNICHEM Service Receipt,/ invoice No. 0 U
<br /> Transporter:
<br /> Authorized
<br /> 2349 Lincoln Avenue Facility: k,J
<br /> Hayward,CA 94546
<br /> EPA ID:CAR000161836 ..."c
<br /> J InAt 1 k
<br /> 800,052,5455,510.785.5455
<br /> 24-Hr Ernprgency No:
<br /> Tran$Pcirtar
<br /> Menffesl No.
<br /> ................
<br /> Customer/
<br /> Gena tutor; I Generator EPA ID#------
<br /> Customer Account
<br /> Generator Status: SOG i CESQG(40CFR 261.6)
<br /> CESQG Certification Initial-, Z�4
<br /> Drums Delivered 30-gal 55°981 Drums PIckod4Jp:
<br /> Open PlastictMetal
<br /> Closed Plastic
<br /> DOT Description of Hazardous Waste Quantity Waste Common Unit Unit Price Amount Due
<br /> Code Description
<br /> RO,Waste Tetrachloroethylene,6.1,UN1897,1110 1
<br /> (F002) CA751 Still Residue
<br /> Solid Residue
<br /> RQ,Waste Tetrachloroethylene,6.1,UN1897,III SUnclard
<br /> (F002) CA751 Split
<br /> ............ ..........
<br /> RQ,Hazardous Waste.Liquid,n .o.s.,9,NA 308Z III CA134 Wastewater h!- —------------
<br /> (Petroleum Distillates.Tetrachloroethylene)(D039) 1+: p.u,0 $1 V-(9)
<br /> Non-RCRA Hazardous Waste Liquid CN213 Still Residue "i 04 P
<br /> r
<br /> )
<br /> (Petroleum Distillates,Green rarth,RynexSolid Residue
<br /> Non-RCRA Hazardous Waste Solid Standard
<br /> (Petroleum Distillates,Green Earth,Ryney) ...,,CA213 Split
<br /> .............. ......... ...........
<br /> *o SUBTOTAL
<br /> Outstanding Account Balance:
<br /> Payment Check Other:
<br /> ...............
<br /> Check#: Amount:
<br /> Dt") .............. Energy Surcharge
<br /> TOTAL AMOUNT DUE
<br /> Please Pay C.O.D (includes outstanding a/c bal.if any)
<br /> I certify that the hazardous wastes named above are properly classified,described, and packaged. These wastes are stored in undamaged containers
<br /> that contain only the wastes as described,.and are in proper condition for transportation per applicable DOT regulations. I further acknowledge that I
<br /> have the authority to enter into the service agreement printed on the reverse, that I understand Vie,rotor airg)4int(lug will tae peu(j C.0,1J, oigess crttdit
<br /> hats hone Pxfondpd by Toehnir-hi-m. in which f1r.I.Sn,f)ayrnprit;.q dim Within 19 days of the date ntservica
<br /> I also certify,ff indicated as such by my initial above,that the wastes above are generated by a conditionally exempt small quantity generator(CESQG)
<br /> as defined In 40 CFR part 261,5, and as such, per 40CFR part 268.1,these wastes are not subject to any land disposal restriction provision of 40CFR
<br /> part 268. Pursuant to HSC Soo 25160.2 (b)(4)(H), I also Certify that I have established a program to reduce the volume or quantity and toxicity of the
<br /> hazardous Waste to the degree as I have determined to be economically practicable.
<br /> Print f curtamer
<br /> cuatowker Nnmc—. Igrwtur@:_ Dow;
<br /> Pursuant to HSC Ser 25160,2 (c)(2' 'r- m h y1c al hazardous waste above will only be transported to an authorized
<br /> .0
<br /> ,d
<br /> .f"Ijk
<br /> .I, P ransportod to a storage or transfer facility in accordance with the
<br /> hazardous waste treatment facility and k lVED
<br /> r
<br /> applicable provisions of the low.Technic, am oes noi`iake title to customer generated waste or other material.While exercising proper care and safety
<br /> precautions,I have removed the wastes above from the customer's promises and accepted tha,materials for transport on the date undersigned below
<br /> DrIver/Oftice Mama:
<br /> 1-`E C 17 Z014
<br /> Sig
<br /> n turVI./, Dato:
<br /> ENVIRONMENTAL HEALTH
<br /> DEPARTMENT
<br />
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