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Pa�mFrREMOtJ �o SE4VIRONMEN1TAL S*RVICES, INC. <br /> Send INVOICE # " 6 6 7 <br /> P.O.Box?8-5 Phone: '0 -4 t8-3'00 U.S.D.O.T.#1484667 � v <br /> Vacaville.Ca 95696-2875 Fax: "0 -W8-3499 D.T.S.C.#3544 Date <br /> Ni�xir.hazwasteremoval.com CA#274461 <br /> SITE ADDRESS BILLING/MAILING ADDRESS <br /> Customer_Rrannnn Tirp. Customer 2mr'on Tire <br /> r;1 i.'t(. Gl �i his <br /> -f to"! �'? i+•li� 1 . <br /> E.P.A. # ~ r r i F_ Phone <br /> Additional Contacts: <br /> i 'd7 <br /> PRODUCT - iERVICE INFORMATION PROPER SHIPPING DESCRIPTION <br /> 7 • 14 • 21 • 30 • 4S • 60 • 90 180 • 365 W/C WASTE MANIFEST NUMBER QUANTITY UNITS PRICE AMOUNT <br /> CODE <br /> _ - - - -- •moo � -� iU <br /> C. <br /> _^^p`v Re-ave ':A'. 'A2 5g ZI IOg ❑ 15g❑ 30g ❑ 55g ❑ S P F <br /> Clor-LD-Tect Q400C TeST K7-: 7es- ❑ Pass ❑ -ai- ❑ Generator Knowledge `] PPM.<; <br /> Transportation Charges/Additior•ai .ruck ilme/Additional labor/LAB Packing/Site Cleaning <br /> Clean: Y N Labels' Oil A/F UOF . Oily Deb <br /> SERVICES REQUESTED BY TAX 1 911)o <br /> We `V P. O.# TOTAL CHARGES: <br /> Accept 6� <br /> GEN lRATOR'S CERTIFICATION: cescrbed above by proper shipping name and are classified,pocked,marked,and <br /> c.a s+c•e arc notional government regulations. If I am a large quantity generator,I certify Ihat 1 <br /> -:,-e ceg-ee:^ :e ce'er.^ined to be economically practicable and that I have selected the practicable method <br /> -- ec .re'rrea'•o numan health and the environment:OR.if I am a small quantity generator,I have made <br /> •- - ' - _---- •- =r - - -- _ <br /> -3::"-e cesr.•-' s-e^- „e-e -a nac iha•'s^vc7loble to me and that I con afford. All used oil from the generator listed above <br /> =e'='s-`e=- - -- - - - e_sec c -,c rec:•c ec oi-oe a fociiity trot is required to comply with Federal regulations appricabte to the <br /> ;<^' y -=c'ec czc-:<_cscc:c-eC wi•�•-.s-este has beer.disclosed. The customer agrees to pay reasonable costs and attorney <br /> fees -e='- -_- = _ _ _ _ - _=e4or n_-=ses^ -s ob::oation sYcF oe Jn Sai=nc-cur),:. I declare under penal of u that the for is true and cort zr- <br /> ,BS POSAL/RECYCLING FACILITY: Collection Station Industrial Agriculture Government Marine Other lnduss�l � Lu ricoftng <br /> on <br /> r35 rhe"lands Pr. Easi <br /> r ':"�7 j„'✓•�'C;;; ••qty cvKi` 3.9 <br /> P11n Generators Signature�t levees Si re <br /> Stat Law Requires that you keep this Recelpt/8111 of lading on file no iess�an 3 years y �� <br /> Tr\R .-A r+hrn+o n•+n nh+nln...+Cao S.r,��F....,.... „_,,,ar.,_a nmr n�.nnn — .n.n <br /> ZTT/L£OIn OKI SOAS AN51 MIIORRHA 666£8bbL0LT XVJ 90:VT TTOZ/ZZ/80 <br />