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FRE VIOU E_JVIRONMENTAL S*RVICES, INC. <br /> Send Pai,ment to: Phone: 80 -=59-_ EPA ID=CAR000171017 <br /> P.U. Boy 2875 Phone: '0 448-3700 li.S.D.O.T.#1484667 INVOICE # 14290 <br /> Vacaville.Ca 95696-28"5 Fax: 70 -448-3499 D.T.S.C.#3544 � <br /> www.hazwasteremoval.com CA#274461 Date J <br /> SITE ADDRESS BILLING/MAILING ADDRESS <br /> Customer �' Customer;��,t,�, � <br /> C <br /> r' 1�i(- I <br /> ,. <br /> E.P.A. # " ,r.r �,'�" Phone Fax <br /> Phone Numbers: Office Cell <br /> Contact: ( ;t�rlcc <br /> PRODUCT - S RVICE 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 1 A 1 1 A2 5g ❑ l Og ❑ 15g ❑ 30g❑ 55g ❑ S P F <br /> Clor-D-Teat Q4000 Test Kit: Test Z3P ss❑ Fail ❑ Generator Knowledge; -;PPM s <br /> Transportation Charges/Additional Truck Time/Additional Labor/ LAB Packing/Site Cleaning <br /> Clean: Y N Labels Oil A/F UOF Oily Debris <br /> SERVICES REQUESTED BY TAX 1 8,00 <br /> Acce t P. O. # TOTAL CHARGES: '�' <br /> is <br /> GENERATOR'S CERTIFICATION: :hereby devare+hat'he onteris of".hj3 Corsignment ore fully and accurately described above by proper shipping name and are classified,packed,marked,and <br /> labeled.and are in all respect3 Ir,proper Condition fcr tr ;:sport by highway according to opplicoble stote and notional government regulations. If I am a large quantity generator,I certify that I <br /> have a program in place to reduce he volume and foxi ity of woste generated to the degree I have determined to be economically practicable and that I have selected the practicable method <br /> of treatment.storage.or disposal currently available to nie which minimized the oresent and future threat to human heolih and the environment;OR,if I am o small quantity generator,I have made <br /> a good faith effort to minimize my waste generation and select the best waste management melhod that is available to me and that I con afford. AN used oil from the generator listed above <br /> will be transported oniv'c c facGh cermttfed by she S•c a Of Ca!aorn a Tia orcauce used ail;nto recvcied al OR a facility that is required to comply with Federal regulations applicable to the <br /> managBTent at use0 C'. a•re;e`.a--^'a: •ega' '.a 91C—"u,3Cspectec':azo,as Csscea"ed rtn.`his waste nos been disclosed. The customer agrees to pay reasonable costs and attorney <br /> tees incurred-,r-.e cc'rec•'n a''-'Tis a�i^c':o^ ':a❑ue' ureases of;nis o06 otion$nail!oe in Soicno county. I declare under enali of perjury that the for oin is hue and correct. <br /> DISPOSAL/RECYCLING FACILITY: :] V:ciliection Station Inciustrfal Agriculture Government Marine OtherIndu ilial Oil fing <br /> f _. <br /> or:m, s"sI sntury,EMl <br /> t,awlPnds Ur,Easl <br /> - e <br /> Print Name Generator's Signature er s Sign a fir• (� <br /> Slate L Requires that you keep this Receipt/Bill of Lading on Rle no less�fhah 3 years. <br /> To Re- ctivote or to obtain an EPA#-Customer may contact DTSC O.T-AftA1 R-6949 <br /> ZTT/OZO[8 OKI SOAS ANH MIIONHHA 66VCRVVLOLT XVd £0:VT TTOZ/ZZ/80 <br />