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Customer Manifest Receip Bill of LadinWInvoice <br /> For Service ' <br /> 800-760-0019 <br /> M 1 M <br /> Date (.iCD <br /> r; <br /> (� BILLING INFORMATION <br /> Z N NAME CASH U CHECK U <br /> 'n o # <br /> h <br /> W � 1 • ADDRESS CONTACT NAME <br /> a 0 CITY STATE ZIP CO PO# <br /> !, K PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. <br /> AMT O <br /> mSTE <br /> MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> C ODE NUMBER (For Time Of Service Only) <br /> c <br /> E, Efl <br /> (j A 221 Gal <br /> C • <br /> F71 Z <br /> -0 <br /> ® - o A 134 Gal <br /> c <br /> a ' <br /> N <br /> 1:1 El 221 Gal <br /> • <br /> i <br /> L m A 223 Gal <br /> to <br /> S <br /> M Drum <br /> 10 -I r <br /> 0 Cr (D Drum <br /> y <br /> U) Drum <br /> rs 0 en <br /> — 2 z� -n � Hours <br /> >° y _s r« A 133 Gal <br /> L N y a C? a > . CA 352 Gal <br /> v CrW' 'a D <br /> n >_ U) 0 ' CA 331 Gal <br /> 0 E: 0 • <br /> i o CA 1D <br /> mia �� • 6 <br /> = � `c ✓1 <br /> O 6 <br /> n m O <br /> O <br /> d <br /> C.. FAIL❑ PPM Test <br /> A&S Environmental Services as the transporter of your TOTAL <br /> Hazardous waste may use another licensed transporter to CHARGES <br /> haul your waste to a designated facility. <br /> I <br /> DESIGNATED TSDF: U EVERGREEN ENVIRONMENTAL• 80 Smith Avenue•Newmark,CA•CAD982413262•(800)972-5284 <br /> U RAMOS ENVIRONMENTAL• 1515.River Road•W.Sacramento,CA 95691•CAD044003556•(916)371-5747 <br /> U RIVERBANK OIL TRANSFER• 5300 Claus Road•Riverbank,CA 95367•CAL000190816•(209)863-8181 <br /> U ALTERNATE FACILITY <br /> U ALTERNATE FACILITY <br /> U ALTERNATE FACILITY <br /> This is to certify that the above named articles are properly classifigd,described,pack- A service charge of 1 1!2%per month shall be charged on all past due accounts. Collections <br /> c— . <br /> aged,marked and labeled,and are in proper condition for transportation,according to costs,including attorney's fees,will be added to past due accounts placed for collections. <br /> of-Transportation. I HEREBY CERTIFY THAT I HAVE NOT MIXED THIS WASTE WITH ANY OTHER <br /> the applicable regulations of the Department o <br /> WASTE,THAT THE TOTAL HALIDES ARE,LESS THAN 1000 P.P.M.;AND THAT <br /> j4l THE WASTE DOES NOT C�OeN�T!A�IN ANY PCB'S. <br /> DRIVER SIGNATURE GENERATOR'S SIGNATURE AMOUNT DUE IN 30 DAYS <br />