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TECHH/CHEM Service Receipt/ Invoice No.
<br /> ific,asap r �.ite. �c}, :.. >_:.;,, `:J Syxtech Env.Corp.
<br /> Transporter. Authorized c+'
<br /> 2349 Lincoln Avenue Facility: 1407 Vukan Rd. flighwaly 9-5-12 mi S.ef 1420 S.('merit did.
<br /> Hayward, CA 94545 Benton,AR 72015 Beatty,NV 49011:3 Fredonia,KS 66736
<br /> EPA ID: CAR000161836 AR D"1057$70 KStD98063 3
<br /> 800.652.5455,510.785.5455 24-Hr Emergency No: InfoTrac#102393: 800.535.5053
<br /> Uniform Hazardous /� Transporter Ref.
<br /> Waste Manifest No 010249��yhul Manifest No. 101.333 Date: 7'1.4/2.02 f
<br /> Customer/ Fork Avenue Cleaners Inc. Generator EPA ID#: x'AL 000 398 057
<br /> Generator: (3 ,j Bran(Alike) Q5376-08
<br /> 2529 Tracy Boidevard Customer Account#:
<br /> Tracy,CA 95376 Generator Status: SQG/CESQGi(40CFR 261.5)
<br /> (100)917 1,7011) t
<br /> CESQG Certification Initial: k
<br /> DOT Containers Delivered 30-gal 55-gal Drums Picked-Up:
<br /> Open Plastic/Metal
<br /> Closed Plastic
<br /> DOT Description of Hazardous Waste Quantity Waste Common Unit Unit Price Amount Due
<br /> Code Description
<br /> RQ, UN1897,Waste Tetrachloroethylene,6.1, III CA751 Still Residue 55-laaj b550,0)
<br /> (F002) Solid Residue 30-gat $390.00
<br /> RQ, UN1897,Waste Tetrachloroethylene, 6.1, III CA751 Standard 55-p1 $5150.00
<br /> (17002) Split .0 - $390.00
<br /> RQ, NA 3082, Hazardous Waste, Liquid, n.o.s.,9, III CA134 Wastewater 55-gta $550.40
<br /> (Petroleum Distillates,Tetrachloroethylene)(D039) 30-gal $390-00
<br /> Non-RCRA Hazardous Waste Liquid Still Residue
<br /> (Petroleum Distillates, n-Siloxane, Glycol Ether(s), <.a` CA213 Solid Residue S_ `,� "
<br /> Green EarthTM, R nexTM) 30- a' $390.00
<br /> Non-RCRA Hazardous Waste Liquid Standard
<br /> (Petroleum Distillates, n-Siloxane, Glycol Ether(s), CA213 Split
<br /> Green EarthTM, R nexTM) 3f 1%390.00
<br /> �,uFP}ies:
<br /> 10T dntm Recon Metal/Poly
<br /> Outstanding Account Balance: SUBTOTAL %
<br /> Payment Check Other/Drums: >ttppfies Taxc:;
<br /> Check#: Amount: `� FPA electronic nlanif4st Energy Surcharge $25-00
<br /> Pay * TOTAL AMOUNT DUE �� ^ �
<br /> Please Pa V■O■D■ (includes outstanding a/c bal.if any)
<br /> certify that the hazardous wastes/materials named above are properly classified, described, and packaged. These items are stored in undamaged
<br /> containers, contain only the items as described,and are in acceptable condition for transportation per applicable DOT regulations. I further acknowledge
<br /> that I have the authority to enter into this service agreement and the conditions printed on the reverse side. Further, `the total amount due will be paid
<br /> C.O.D.unless credit has been extended by Technichem,in which case,payment is due within 15 days of the date of service.
<br /> certify, if indicated as such by my initial above,that the wastes listed 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 the land disposal restriction provision of 40CFR
<br /> part 268. Pursuant to HSC Sec 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 I have determined to be economically practicable. { /+
<br /> Print �y�y Customer A /JJ
<br /> Customer Name: , i''�� �r'"'f� Signature: Awe Date: //( (/�/
<br /> Pursuant to HSC Sec 25160.2 (c)(2)(C), Technichem hereby confirms that all hazardous waste or materials listed above will be transported to an
<br /> authorized hazardous waste treatment facility and that the hazardous waste may first be transported to a storage or transfer facility in accordance with
<br /> the applicable provisions of the law. Technichem does not take title to customer generated waste or other material. While exercising proper care and
<br /> safety precautions, I have removed the wastes above from the customer's premises and;accepted the matprials for transport on the date undersigned
<br /> below.
<br /> Transporter1 4zts, /
<br /> Signature: Date:
<br />
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