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TECHN/CHEM s�jrvice Receipt/Mr.
<br /> voice No. 13 Q_
<br /> Heritage Env.Svcs. S Ecology Systech Env.Corp.
<br /> 20
<br /> Transporter: Authorized 1007 Vulcan Rd. ighway 95.12 mi S.of 1420 S.Cement Rd.
<br /> 2349 Lincoln Avenue Facility: Benton,AR 72015 Beatty,NV 89003 Fredonia,KS 66735
<br /> EPA ID:CAR000161836
<br /> Hayward,CA A"981057870 NVI330010NO KSD980633259
<br /> 016
<br /> 800.652.5455, 510.785.5455 �( 24-Hr Emergency No: VnfoTriac#102393: 800.5800.535.5053Uniform Hazardous 010250 , `4FLE Transporter 101395 Ref. 7/26/2021,
<br /> waste Manifest No. Manifest No. Date:
<br /> Express Cleaners CAL 000 318 568
<br /> Customer/ Abdullah Wakeely Generator EPA ID#:
<br /> Generator: 95377-02
<br /> 2271 West Grant Line Road Customer Account#:
<br /> Tracy,CA 95377
<br /> (209)833-1742 Generator Status: SQGCES (40CFR 261.5)
<br /> CESQG Certification Initial 1
<br /> DOT Containers Delivered 30-gal 55-gal Drums Picked-Up:
<br /> Open Plastic/Metal
<br /> Closed Plastic s
<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 -$550•3Q-gal $390�
<br /> (F002) Solid Residue
<br /> —3 -5556.
<br /> RQ, UN1897,Waste Tetrachloroethylene,6.1, III CA751 Standard 30- $390.D0
<br /> (F002) Split
<br /> RQ, NA 3082, Hazardous Waste, Liquid,n.o.s.,9, III 3 R1 5550
<br /> (Petroleum Distillates,Tetrachloroethylene)(D039) CA134 Wastewater 30-gal $390.00
<br /> Non-RCRA Hazardous Waste Liquid Still Residue 550.00
<br /> (Petroleum Distillates,n-Siloxane, Glycol Ether(s), CA213 olid esi e '
<br /> Green Earth , R nexT
<br /> Non-RCRA Hazardous Waste Liquid tandaPd - _X550•
<br /> (Petroleum Distillates, n-Siloxane,Glycol Ether(s), CA21 <1111� $-'_3_9_6;1}0
<br /> Green EarthTM, R nexTm) ©'
<br /> up es:
<br /> DOT drum Recon Metal/Poly Y5— G
<br /> Outstanding Account Balance: 1 SUBTOTAL '
<br /> Payment, Check Other/Drums: Supplies 1 Taxa
<br /> Check#: Amoi t: " O'0 EPA electronic Manifest/ Energy Surcharge 25•00
<br /> TOTAL AMOUNT DUEPlease Pay C.O.D.* �
<br /> (includes outstanding a/c bal.if any) � �' C,/
<br /> I 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 /> 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 /> Printp Customer
<br /> Customer Name: c ! ��N Signature: tEO
<br /> \ NC1 6Ci.. 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 d accepted the m terials for transport on the date and signe
<br /> below. .a
<br /> Transporter
<br /> Signature: _ Date: f
<br />
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