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rECK11\` llll Wil'-7� ���iil - evvice Receip , / invoice No . 129273
<br /> Transporter : Authorized -Ier(tage linty. Svcs. E1 LIS Ecology i l Systeclt Env. Corp .
<br /> 2349 Lincoln Avenue j Facility : 1007 Vulcan Rd. 141gltliray 95 - 12 lilt S .01' 1420 Ne Cement Rd .
<br /> Hayward , CA 94545 Benton, AR 72015 Beatty, NV 89003 Fiv.. tiotda , KS 66736
<br /> EPA ID : CAR000161836 ARD9810578 70 NNIT330010000 KSD930633259
<br /> 800 . 652 . 5455, 510.785. 5455 24-Hr Emergency No : InfoTrac #102393. 8 0 .535.5053
<br /> Uniform Hazardous Transporter Ref.
<br /> CMow il i
<br /> Waste Manifest No. Manifest No. Date:
<br /> Customer/ Generator EPA ID #:
<br /> Generator: j Y�.y' p� /
<br /> 43 /9, 1 � L l�/1C Customer Account #: / S) 7 `�
<br /> C4 Generator Status: SQG / CESQG (40CFR 261 . 5)
<br /> J ,
<br /> CESQG Certification Initial : r'
<br /> DOT Containers Delivered 30-gal 550gal Drums Picked-Up:
<br /> 0 Age
<br /> Open Plastic/Metal i t
<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_ xal x; 550 . 00
<br /> ( F002) Solid Residue
<br /> RQ, UN1897 , Waste Tetrachloroethylene , 6 . 0I , III CA751 Standard -r al $ 550 .00
<br /> ( F002 ) :Iplit .30-g;.! [ $390 . 00
<br /> RQ, NA 3082 , Hazardous Waste, Liquid , n.o.s. , 9, III CA134 Wastewater 5 ' -) ; A $ 550 .00
<br /> (Petroleum Distillates, Tetrachloroethylene) (D039) 30 - z, il `ti390 , 00
<br /> Non-RCRA Hazardous Waste Liquid esidue
<br /> (Petroleum Distillates, n-S11oxane, Glycol Ether(s), CA213 ue ti
<br /> Green Earth-rm, R nexTm ) (} _ , X390 .00 l Q
<br /> Non-RCRA Hazardous Waste Liquid Standard
<br /> (Petroleum Distillates, n-Siloxane, Glycol Ether(s), CA213 Split � • ' 'f `! I j ' � {) • {lO
<br /> Green Earth-rm, RynexTM) `01) 0 00
<br /> Supplies :
<br /> DOT chlrnt Recon \detail ! Poly
<br /> Outstanding Account Balance: SUBTOTAL
<br /> Payment , j�' ` Check Other/Drums: St ! [�l >lies ! " 1 'aA I
<br /> Check #: AfJ
<br /> V mount: �' � S , OQ
<br /> F, P11 c`l ; e;Ircatic: rnaniG si / Energy Surcharge
<br /> TOTAL AMOUNT DUE
<br /> Please Pay C . O . D . *
<br /> (includes outstanding a/c bol. if any)
<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 /> Print Customer n ,
<br /> Customer Name: Signature: Date: j
<br /> Pursuant to HSC Sec 25160. 2 (c)(2)(C ), Technichem hereby confirms thathazardous waste or materials 118ted 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 a cepted the materi for transport on the date unders'gned
<br /> below.
<br /> Transporter
<br /> Signature: Date:
<br />
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