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I <br /> FRE-NI ' E VIRONMENTAL SbRV1(ES91AU* <br /> :;end Pa%ment to: Phone: ? 0-559-3EPA ID=CAR000171017 <br /> P.O. Box :8"5 Phone: _ -148-3-00 li.S.D.O.T.# 1484667 - INVOIICY # 1. 033 <br /> VacaN ille.Ca 95696-2875 Fax; 7 7-448-3499 D.T.S.C.#3544 Date "f /-c;)-`f <br /> vi-A-w.haz%vasteremoval.com CA#274461 <br /> SITE ADDRESS r I i 1f1r BILLING/MAILING ADDRESS <br /> r li.�, i.:t Tire' <br /> Customer ' " Customer <br /> ` ,remo t Avenue �t .,fit B ox �q�g <br /> tni r; . : 2;^ _ N. 95201 <br /> V <br /> E.P.A. # �..'AL 000 196 5�� '� Phone Fax <br /> Phone Numbers: OfficetCell <br /> Contact: <br /> PRODUCT • SERVICE INFORMATION PROPER SHIPPING DESCRIPTION <br /> 7 14 . 21 30 45 60 90 180 365 W/C WASTE MANIFEST NUMBER QUANTITY UNITS PRICE AMOUNT <br /> CODE <br /> Empty Drums Provide Remove D 5g ❑ l Og ❑ 15g ❑ 30g ❑ 55g ❑ S P F <br /> Clor-D-Tett Q4M*0 Test Kit: Tes±❑ Pass❑ Fail ❑ Generator Knowledge 45- PPM <br /> ^spc c� C- goes;Addl"c^ciTA <br /> ck 71-re/Additional Labor/LAB Packing/Site Cleaning <br /> I <br /> Clecr.: ti abe!s V' Ci! :" A/F J,, i G; UOF'; kr Oily Debris <br /> SERVICES REQUESTED BY TAX I 8.Qu <br /> We P. O.# TOTAL CHARGES: <br /> Accept <br /> GENERATOR'S CERTIFICATION: "__- 5.__ - _ ._ -.CC-s.^^'3-•�'e - cescribed above by oroper Shipping name and are classified.packed.marked,and <br /> --- - -== "_ --=--- c-•-_ =--- - = - _ c_c _ _ c e sc a c-c na iera cover,:ment regulations, it I am o large quantity generator,[certify that I <br /> o.,e ze-e—'.-ed to be eccromicolly orocticable and that I have selected the practicable method <br /> _ ::-z:_c_ _ _ -- -= �-_ - c-0`�_•e•__ Kumon health one the environment;OR.if!am a small quantity generator.[have made <br /> c - - =- -= _ ^-e- _ ^vosable'o me and+`ct!ccr,afford. All used oil from the generator fisted above <br /> T' - caec-e-c'OR c`ociGty thct is required fo comply with Federal regulations applicable to the <br /> 'ees. -e "' "-= _ __- - _ =oec eo-czc'cs c_ _c ed:•. - cs a 1105 been disclosed. The customer agrees to pay reasonable costs and attorney <br /> ees" -V - can oe C-Sc,anc co ^`. :declare under penalty of perjury that the forepoing is true and correct. <br /> DISPOSAL/RE-CYCLING FACILITY: Collection Station Industrial Ag <br /> IjOUlture Government Marine Other t^duasfrlal I Lubrlcl ting <br /> r ..- - ,... .. _---Y-• ,. r �_ 1121st dun•BMs <br /> ":ewlandDr.,Eml <br /> "31Af, _ -_. f^ . - Q C•'.I',F"-rl -S-G�g�t.'60 iJ!D9&OLi35a'ft <br /> P'nt dme Generators Signature Driver's Signature <br /> State Law Requires that you keep this Reeeipt/Bill of Lading on me no less than 3 years. <br /> To Re- ctivate or to obtain an EPA#-Customer may contact DTSC® 1-800-618-6942 <br /> ZTT/VT01n OKI SOAS AKH MIIONRUA 66VRRVVLOLT XV9 TO:bT TTOZ/ZZ/80 <br />