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TECHN/CHEM Service Receipt/ Invoice No. 129099
<br /> Transporter: Authorized eritage Lily.Svcs. 0 IIS Ecology E Systec':h Env.Corp.
<br /> 2349 Lincoln Avenue Facility: 1007 Vulcan Rd. Highway 95-12 mi S.of 1420 S.Cement Rd.
<br /> Hayward,CA 94545 Benton,AR 72015 Beatty,NV 89003 Fredonia,KS 66736
<br /> EPA ID:CAR000161836 ARD981057870 NVT330010000 KSD980633259
<br /> 800.652.5455, 510.785.5455 24-Fir Emergency No: InfoTrac#102393: 800.535.5053
<br /> Uniform Hazardous Transporter Ref.
<br /> 101282 10" 2019
<br /> Waste Manifest us Manifest No. Date:
<br /> Customer/ Express Cleaners Generator EPA ID#: 9-A4, '�� ,r�
<br /> Generator: Abdullah.Wakeely
<br /> 22.71 West Grant Line Road
<br /> Customer Account#: 45377-02
<br /> Tracy,CA 95377 Generator Status: SQGCESQG 40CFR 261.5)
<br /> (209)833-1742
<br /> CESQG Certification Initial: 61
<br /> DOT Containers Delivered 30-gal 55-gal Drums Picked-Up:
<br /> Open Plasti Meta � �-
<br /> Closed Plastic
<br /> DOT Description of Hazardous Waste Quantity Waste Common Unit Unit Price Amount Due
<br /> Code Description
<br /> RQ, LIN 1897,Waste Tetrachloroethylene, 6.1, III CA751 Still Residue 55-get( $550,00
<br /> (F002) Solid Residue 30-gal $390.00
<br /> RQ, UN1897,Waste Tetrachloroethylene,6.1, III Standard 55-gal $550.00
<br /> (F002) CA751 Split 30-gal $390.00
<br /> RQ, NA 3082, Hazardous Waste,Liquid, n.o.s.,9, III 55-gal $550.00
<br /> Petroleum Distillates,Tetrachloroethylene) CA134 Wastewater
<br /> ( Y ) D039( ) 30 <>;
<br /> $390.0('
<br /> Non-RCRA Hazardous Waste Liquid till l 550.0
<br /> (Petroleum Distillates, n-Siloxane,Glycol Ether(s), . CA213 Solid Residue ` - Ott.
<br /> Green EarthTM R ne'TM 30-gal $390.0() .
<br /> Non-RCRA Hazardous Waste Liquid Standard 55-gal $550.00
<br /> (Petroleum Distillates, n-Siloxane,Glycol Ether(s), CA213 Split
<br /> Green EarthTM, R nexT^") 30-gal $390.00
<br /> Supplies:
<br /> DOT drum Reconetal: Poly �� 9-�~ "Cv
<br /> Outstanding Account Balance SUBTOTAL
<br /> Payment Check � Other/Drums: Supphes/Taxes
<br /> Check#: C/ Amount: o•cr :`. PA electronic inane est i Energy Surcharge
<br /> Please Pay C O * TOTAL AMOU�RT DUE ® �,
<br /> ■ ■ ■ (includes outstanding arc bol.i�#iy)
<br /> 1 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 dads of the date of service.
<br /> I 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 — 1 ,� 4—•--- Customer 1 /, /� r
<br /> rnfl
<br /> �
<br /> Customer Nae: " ' t � � Signature._ .."� '� Date:
<br /> t
<br /> Pursuant to HSC Sec 25160.2 (c)(2)(C), Technichem hereby confirms that all hazardous wa o 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 a accepted them rials for transport on the date under gned
<br /> below.
<br /> Transporter
<br /> Signature: _ Date: 4
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