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io(p M1 IV11U1 it I ici rtcu vci vivv.� <br /> '.O. Sox•186 z <br /> -aGrange, CA 95329 For Service <br /> 209)_538-0886 / Fax (209) 53 -2498 800-760-0019 <br /> .PA# CAR000176537 Date <br /> JOB LOCATION BILLING INFORMATION <br /> NAME NAME CASH U CHECK❑ <br /> F <br /> ADDRESS ADDRESS CONTACT NAME' <br /> CITY STATE CO CITY STATE ZIP CO PO#i <br /> PHONE NO. PHONE NO. PROFILE NO. CUSTOMER EPA ID NO. <br /> PRODUCT WASTE MANIFEST QUANTITY UNITS PRICE AMOUNT <br /> CODE NUMBER (For Time Of Service Only) <br /> Used oil,Non-RCRA Hazardous Waste,Liquid CA 221 r-:. �' Gal <br /> Gal <br /> Used Automotive Antifreeze,Non-RCRA Hazard s CA 134 _ s <br /> Waste,Liquid <br /> Non-RCRA Hazardous Waste Liquid CA 221 Gal <br /> Used Oil&Water <br /> Oil&Water,Non-RCRA Hazardous Waste Liquid CA 223 Gal H <br /> Drum - <br /> Empty Drum Delivery <br /> Empty Drum Pick Up Drum <br /> ' <br /> Drained Used Oil Filters Drum <br /> Non-RCRA Hazardous Waste Solid CA 352 <br /> Waste Flammable Liquid Gas CA 133 Gal <br /> Waste Flammable Liquid Paint CA 331 Gal <br /> California Energy Surcharge 10% <br /> Credit Card Fee <br /> Bridge Toll <br /> Hours <br /> Labor <br /> Other: <br /> Other: <br /> Other: <br /> Tax <br /> TEST PASS❑ FAIL U PPM T Test <br /> Collection Station ❑Agriculture Source A&S Environmental Services as the transporter of your TOTAL <br /> U Government Source ❑Industrial Source Hazardous waste may use another licensed transporter to CHARGES <br /> ❑Marine Source haul your waste to a designated facility. <br /> DESIGNATED TSDF: U D/K ENVIRONME TAL• 7300 Chevron Way•Dixon,CA 95620•CAT080012602•(707)693-6008 <br /> ❑RAMOS ENVIRO MENTAL• 151 S.River Road•W.Sacramento,CA 95691 •CAD044003556•(916)371-5747 <br /> .Q RIVERBANK OIL SFER• 5300 Claus Road•Riverbank,CA 95367•CAL000190816•(209)863-8181 <br /> U BEST ENVIRONMENTAL• 2430 Almond Drive•Silver Springs,NV 89429•NVD982358493•(775)577-9001 <br /> U ALTERNATE FACILITY <br /> ❑ALTERNATE FACILITY <br /> This is to certify that the above named articles are operly classified,described,pack- A late fee of$25.00 per month shall be charged on all past due accounts. Collections costs, <br /> aged,marked and labeled,and are in proper conditi n for transportation,according to including attorney's fees,will be added to past due accounts placed for collections. <br /> the applicable regulations of the Department of Tr sportation. I HEREBY CERTIFY THAT I HAVE NOT MIXED TI-IIS WASTE WITH ANY OTHER <br /> WASTE,THAT THE TOTAL HALIDES ARE LESS THAN 1000 P.P.M.;AND THAT THE <br /> WASTE DOES NOT CONTAIN ANY PCB's. <br /> DRIVER SIGNATURE GENERATOR'S SIGNATURE AMOUNT DUE IN 30 DAYS <br />