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FREMOU E''TVIRONMENTAL SF&RVICES, INC. <br /> Send Payment to: Phone: 8 0-559-3�r-► EPA ID#CAR000171017 <br /> P.O.Box 2875 Phone: 7)7448-3700 U.S.D.O.T.#1484667 INVOICE # 35110 <br /> Vacaville,Ca 95696-2875 Fax: 737-448-3499 D.T.S.C.#3544 <br /> www.hazwasteremoval.com CA#274461 Date <br /> SITE ADDRESS BILLING/MAILING ADDRESS <br /> Customer-' Customer <br /> E.P.A. # Phone <br /> I <br /> Additional Contacts: t, <br /> PRODUCT - SERVICE INFORMATION PROPER SHIPPING DESCRIPTION <br /> 7 • 14 • 21 • 30 • 45 • 60 • 90 • 180 • 365 WAC WASTE MANIFEST NUMBER QUANTITY UNITS PRICE AMOUNT <br /> CODE <br /> Non-RCRA Hazardous WasteliLUjjqui <br /> Usea(At) I CA 221 O1l 1�►�� r Oil <br /> Non-RCRA Hazardous Waste (Used Anti-Freeze) i:A 134 <br /> Non-RCRA Hazardous Waste (Oily Water) CA 223 <br /> Drained Used Oil/Gasdine I Diese Filters WA _3s <br /> Non-RCRA Hazardous Waste Sohd(Od Cot tanwded Debris, Sol) CA 223 <br /> UN1960,WasteAeroeas,(EwhNot bceodNIL C4 moty),21'Limded4-idnG1y' -z 11,UW1 flJrj �aS']3f�J`i` <br /> Waste Flarrenabie Liq^RO.S.,3,UNION,RM(Casolir ilmW) 3311DO18 <br /> f.p►d '�'G 4A (Ir,Z,4;L��s 1.�.iS' Ste.. b M-L ?1-' `�� 1 <br /> .r <br /> Empty Drums Provide 0 Remove 1 A 1 1 A2 5g ❑ l Og ❑ 15g ❑ 30g A 55g❑ Si P F <br /> Clor-D-Tect Q4000 Test Kit: Test❑ ass ❑ Fail ❑ Generator Knowledge,,Zj' PPM <br /> Transportation Charges/Additional ruck Time/Additional Labor/ LAB Packing/Site Cleaning <br /> Clean: I Y' N Labels / Oil A/F UOF Oily Debris <br /> SERVICES REQUESTED BY TAX <br /> We Acce t P. O. # TOTAL CHARGES: <br /> GENERATOR'S CERTIFICATION: I hereby declare that W e contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed,marked.and <br /> labeled,and are in all respects in proper condition for transport by highway according to applicable state and national government regulations. If I am a large quantity generator,I certify that I <br /> have a program in place to reduce the volume and t xicity of waste generated to the degree I have determined to be economically practicable and that I have selected the practicable method <br /> of treatment,storage,or disposal currently available t me which minimized the present and future threat to human health and the environment;OR,if I am a small quantity generator.I have made <br /> a good faith effort to minimae my waste generation a id select the best waste management method that is available to me and that I can afford. All used oil from the generator listed above <br /> will be transported only to a facility permitted by the tate of California to produce used oil into recycled oil OR a facility that is required to comply with Federal regulations applicable to the <br /> management of used oil. All relevant information reg rding known or suspected hazards associated with this waste has been disclosed. The customer agrees to pay reasonable costs and attorney <br /> fees incurred in the collection of this obligation. Venu for purposes o.this obligation shall be in Solana county. I declare under penalty of pedury that the forgoing is true and correct. <br /> DISPOSAL/RECYCLING FACILITY: Colle on Station Industrial Agriculture Govemment Marine Other t"duOs, LubriOiiating <br /> {ij Evergwn Oi ra•D.►o J ul rc ("i Hwbora San Jae.t1G ( sky tZ..."W I UK Umn <br /> "561 Road 308 Smit Aw Mi Sorryin"Road 401 W Ctwrwf Road 7300 Chmwi Way <br /> I Dater,CA 36616 14"'A C:. 31660 iw+Iaue,CJA 951 3 4 Bww.w,CA 3G10 S DwA CA XM <br /> 510 `14400 L'AD3 44 4 51073134400 tAD9t30BC1410441091u^ CADQ5349M1310 510.54121 1 CALOT1639 1t11�693600£CAT000D126M <br /> Print Name Generator's SignatureDt1Vet'S Signature <br /> I herebycern that I have read a d have the authorityto bind the above listed generator to the tc rrn>on the reverse side of this form. <br />