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FREiVIOUW E'VIRONMENTAL S jfVIC;ES, INC;. <br /> Send Pa%ment to: Phone: 800- 9- EPA EPA ID 0 CAR000171017 , 13 71 <br /> P.O-Box 281-4 Phone: 707 8-3700 U.S.D.O.T.#1484667 INVOICE # <br /> Vaca%ille.Ca 95696-2875 Fax: 707-98-3499 D.T.S.C.#3544 t// <br /> www.hazwasteremoval.com CA#274461 Date <br /> SITE ADDRESS BILLING/MAILING ADDRESS _ <br /> Customer D �f 1 Customer Prann�;n 1 ICP. <br /> P _ x i <br /> -496 <br /> E.P.A. # ��•�- V Phone Fax <br /> Phone Numbers: Office Cell <br /> Contact: ail8 ; L' - - <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 D-u-s orovide = Remove 1 A i 1 A2 5g ❑ i Og ❑ 15g I] 30g 0 559 0 S P F <br /> C!or-D-ec`G4000 Test K'':: Test 7 P ss 0 Fail 0 Generator Knowledge a PPM <br /> Transportation Charges/Additional Trick Time/Additional Labor/ LAB Packing/Site Cleaning <br /> Clean: Y N Labels oil ;. A/F j // ;=� UOF �, Oily Debris 0o / <br /> SERVICES REQUESTED BY TAX 8.00 <br /> We ' <br /> Acce t P. O. # TOTAL CHARGES: <br /> �. <br /> GENERATOR'S CERTIFICATION: =_. __ -- -- _ _ __ _ ..c_•a•e: oesc^'beo cbove by=racer sf•;pp;ng nome and are classified,packed,marked,and <br /> c .ere ccve• en•reg:ac`ons. If 1 am o large quantity generator,I certify that I <br /> c.'e-c'cr'c- - _ _-__ "_ - -_ = c = = c_e e _sc-z: -e;-ee "c.,e cere^:red to be aconorc:co':oro_ricable and that I have selected the practicable method <br /> _-. __ :• _c= - _ - _ _____ c-- __e'-ec' o r ar n=a!' crC me envlrnren:OR,if,am o small quantity generator,I have made <br /> -=- 2 __- __' _.9= -__ _ - c _: ._i'9'-'- - _ c s c•: Ic•re and icon cftard. All used o7 from the generator listed above <br /> • OR a cci i-v rf•,,.;s re.-�:red Comoly with Federal regulations applicable to the__ c�sc=avec -_ cs a-as been disdotec. 're customer agrees to pay reasonable costs and attorney <br /> ,eel -ec : _c - _- _ _ - __ocses: o oe it Soic-.,..o',rv. :deciore under cenaity of pequry that the forgoing is true and correct. <br /> DISPOSAL/RECYCLING FACILITY: Collection Station Industrial Agriculture GovemmentMarine Other Indusstdol Lubrlcoting <br /> ol,c. 12�905 1,"ands Dr,East <br /> ` Prem'eY.fW 89M <br /> ;,r`_",''c'?moi P."�DltQ\iic� <br /> PTInt Name. Generator's Signature Drivers Signa e <br /> state Low Requires that you keep this Receipt/Bill of Lading on file no less than 3 years. <br /> To Re ct!vote or to obtain an EPA#-Customer mnv rnntnr t nTSC.a 1-19r"t n_,we9 <br /> ZTT/LT012 ONI SOAS ANH MfIONFIHA 66V99VVL0LT XVd ZO:6T TTOZ/ZZ/80 <br />