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Jun 1.6 09 11 : 42a Jeff Kindorf 2098207818 p. 3 <br /> A&S Environmental Services Bili of LadinWInvoice <br /> P.O. Box 186 For Service <br /> LaGrange, CA 95329 800-760-0019 <br /> (209) 538-0886 / Fax (209) 538-2498 <br /> EPA# CAR000176537 Date <br /> JOB LOCATION BILLINC INFORMATION <br /> NAMR CASA CJ CHECK❑ <br /> NAME # <br /> ADDRESS ADDRESS CONTACT NAME <br /> CITY STATE ZIP Co CIIY STATE ZIP CO PO# <br /> PHONE NO. PROFILE NO. CUSTOMER EPA 1D NO. <br /> PHONE NO:) ( ) <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER Gal (For Time Of Service Only) <br /> Used oil.Non-RCRA Hazardous Waste.Liquid CA 221 <br /> Used Automotive Antifreeze.Non-RCRA Hazardous CA 134 <br /> Gat <br /> Waste.Liquid <br /> Non-RCRA Hazardous Waste Liquid <br /> CA 221 Gal <br /> Used Oil&Water <br /> Gal <br /> Oil&Water.Von-RCRA Hazardous Waste Liquid CA 223 <br /> Drum <br /> Empty Drum Delivery <br /> Drum <br /> Empty Drum Pick Up <br /> f Drum <br /> Drained Used Oil Filters <br /> Hours <br /> Labor <br /> Waste Flammable Liquid Gas <br /> CA 133 Gal <br /> Non-RCRA Hazardous Waste Solid <br /> CA 352 Gal, <br /> Waste Tires <br /> Waste Flammable Liquid Paint <br /> CA 331 Gal <br /> Other: <br /> Other: <br /> Other: <br /> Other: <br /> Other: <br /> Tax <br /> TEST <br /> PASS❑ FAIL❑ PPM Test <br /> LI Collection Station ❑Agriculture Source A&S Environmental Services as the transporter of your TOTAL <br /> ❑Government Source ❑Industrial Source Hazardous waste may use another licensed transporter to CHARGES" <br /> LJ Marine Source haul your waste to a designated facility. <br /> DESIGNATED TSDF: ❑EVERGREEN ENVIRONMENTAL• 80 Smith Avenue•Newmark.CA•CAD992413262•(800)972-5284 <br /> ❑RAMOS FNVIRONNIENTAL• 151S.River Road•W.Sacramento.CA 95691 •CAD044003556.(916)371-5747 <br /> ❑RIVERBANK OIL TRANSFER• 5300 Claus Road•Riverbank,CA95367•CAL000190816•(209)863-8181 <br /> D ALTERNATE FACILITY <br /> ❑ALTERNATE FACILITY <br /> 0 ALTERNATE FACILITY <br /> This is to certify that the above named articles are properly classified,described.pack- A service charge of l I/2%per month shall be charged on all past due accounts. Collections <br /> costs.including attorney's fees.will be added to past due accounts placed for collcctions. <br /> aged,marked and labeled,and are in proper condition for transportation,according to I I IEREBY CERTIFY THAT I HAVE NOT MIXED THIS WASTE WITH ANY OTHER <br /> the applicable regulations of the Department of Transportation.. WASTE„THAT TIME TOTAL HALIDES ARE LESS THAN 1000 P.P.M.;ANT)THAT <br /> TI IE WASTE DOES NOT CONTAIN ANY PCB-S. <br /> GENL''BATOR'S SIGNATURE AMOUNT DUE IN 30 DAYS <br /> DRIVER SIGNATURE <br />