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f'iZL1V OU W LN VIRONMENIAL SLRVICES itsc. <br /> Send Payment to: Phone: 800-559-3274 EPA ID#CAR000171017 CSLB A-Eng#1022665 <br /> 6940 Tremont Road Phone: 707-448-3700 U.S.D.O.T.#1484667 Small Business#56427 INVOICE # <br /> Dixon,CA 95620 Fax: 707-448-3499 D.T.S.C.#3544 <br /> www.hazardoiisdisposal.net CA#274461 Date <br /> SITE ADDRESS BILLING/MAILING ADDRESS <br /> Customer t =--' t°.; Customer <br /> i�J��"3 tP��l.l� # s� • o t .°`..,s't,t��a�;�, � �`vMt�ir,.� <br /> "a <br /> 8od),PP1 r1 ",'A L 36 ' 3 <br /> E.P.A. # WPhone 6 965 eH6 <br /> Additional Contacts: #2605701 PAYMENT TERMS: <br /> PRODUCT-3ERVICr INFORMATION/PROPER SHIPPING DESCRIPTION/BILL OF LADING <br /> 7 14 21 • 30 • 45 • 60 • 90 • 180 • 365 W/C WASTE MANIFEST NUMBER QUANTITY UNITS PRICE A <br /> CODE <br /> i IL <br /> SERVICES REOIJESTED BY TAX <br /> Accent I00m* P. O.# TOTAL CHARGES: <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,pocked,n <br /> labeled,and are;n 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 c <br /> have a program in place to reduce the voluAe and toxicity of waste generated to the degree I have determined to be economically practicable and that I have selected the praati+ <br /> of treatment,storage,or disposal currently available to me which minimized the present and future threat to human health and the environment;OR,If I am a small quantity generator <br /> a good faith effort to minimize my waste generation and select the best waste management method that is available to me and that I can afford. All used oil from the generator lister <br /> will be transported only to a facility permitted by the State of California to produce used oil into recycled oil OR a facility that is required to comply with Federal regulations applicable <br /> . ., .., .. .. ,• _,.+..,,.,..._..:.__.___:__.. .�.w..,....._a�.tip,.:,NeF..+:,,•..;+ _ einn nhlo mete <br /> fees incurred in the collection of this obligation. -u or n S a be in., la TNT„ e for is <br /> ru an <br /> Venue for ur oses of this obligation shall be in Solana county. I declare under penalty ofperjurythat the forgoing is true and correct. <br /> cd I <br /> DISPOSAL/RECYCLING FACILITY: Collection Station Industrial Agriculture overnent Marine Other Ind Oil <br /> Gm <br /> k9ata�•'A to+�.:'r •�:x� <br /> 11.i-0,'V,—+,+ra <br /> I hereby certify that I have read and have the autkor'to bind the above listed generator to the terms on a reverse side of this If <br /> 7101-Rey,02/17 State Law Requires that you keep this Receipt/Bill of Lading on file no less than 3 years. <br />