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t / Inloce No. 96462 <br /> Service Receipt P <br /> Transporter& Authorized Facility Alternate Authorized Facility: Resolvent, Inc. <br /> 4245 Halleck Street, Emeryville, CA 94608 (if used instead of Technichem) 831 Deming Way, Sparks, NV 89431 <br /> EPA ID: CAD981375983 EPA ID: NVR000076158 <br />�or inquiry or customer service, call (800) 652-5455 <br /> in Southern California, call (888) 998-2436 24-hr Emergency No: Chem-Tel 1-800-255-3924 <br /> Uniform Hazardous Transporter Ref. <br /> Waste Manifest No. 4'524247 Manifest <br /> .�No. <br /> -, Date: <br /> Customer/ (;llle H1)fIr)VlartltllzUtg <br /> 'Generator EPA ID #: <br /> Generator: <br /> (_:hxtlt S Patel Customer Account #: <br /> 5756 Pacific Ave.,Ste I +X °I;" / .� ` <br /> Stouktun,CyA 95207 ����j� �ji�- ��'� -�� � Generator Status: SQG /CESQG (40CFR 261.5) <br /> CESQG Certification Initial: <br /> Drums Delivered: Picked-up: <br /> 20-gal water: _ # <br /> 55-gal water: # -- #-- --- # - _ - <br /> DOT Description of Hazardous Waste Quantity Waste Common Unit Unit Amount <br /> Code Description Price Due <br /> RQ, Waste Tetrachloroethylene, 6.1, UN 1897, III CA751 Still Residue gal <br /> (FO02) Solid Residue <br /> RQ, Waste Tetrachloroethylene, 6.1, LIN 1897, III CA751 Standard each <br /> (F002) Split <br /> RQ, Hazardous Waste, Liquid, n.o.s., 9, NA 3082, III CA134 Wastewater gal <br /> (Petroleum Distillates, Tetrachloroethylene) (D039) <br /> Non-RCRA Hazardous Waste Liquid CA213 Still Residue gal <br /> (Petroleum Distillates) Solid Residue <br /> Non-RCRA Hazardous Waste Solid CA213 Standard each <br /> (Petroleum Distillates) Split <br /> • Outstanding '9 7,t. SUBTOTAL <br /> Account Balance <br /> Payment Check t -� C.O.D. /Volume /Other <br /> Check#: Amount ($�: - _ r Discount %: C �. <br /> TOTAL AMOUNT DUE <br /> Please Pay C. O . D . * '•~�=' <br /> (includes outstanding a/c bal. if any) <br /> I certify that the above-named materials are properly classified, described and packaged, and in proper condition for transportation per applicable <br /> Dept. of Transportation regulations. I also warrant and represent by my signature below that these materials are stored in undamaged <br /> containers and that the containers contain only materials described above. I further acknowledge that I have the authority to enter into and <br /> hereby agree to the terms of the service agreement printed on the reverse, that I understand ' the total amount due will be paid Cash On <br /> Delivery (C.O.D.) unless credit has been extended by Technichem, in which case, payment is due within 30 days of the date of service. <br /> I also certify by my signature below and my initial above that the above-named materials are generated by a conditionally exempt small quantity <br /> generator (CESQG) as defined in 40 CFR part 261.5, and as such, per 40CFR part 268.1, these materials are not subject to any land disposal <br /> restriction provision of 40CFR part 268. <br /> Print Customer <br /> Customer Name: Signature: Date: <br /> Technichem does not take title to customer generated waste or other material. While exercising proper care and safety precautions, I have <br /> .moved the above-named materials from the customer's premises and accepted the materials on the date undersigned below. <br /> dfivedaffice memo _. <br /> ,4181.w,1iJ ..s.,._ �,+. �.:-,�. :;;.:q;a �,is r.:l.., +r pppOaTt'tat@ITtAtrlICRIL <br /> C'ttui-ge credit card on We and tbo% copy of receipt t0 209- <br /> Transporter Signature: <br />