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FREMOUVV E JAYMON MENIAL *KV1U.LN9 nu. <br /> S-End Pa%ment to: Phone: 00-'59 4 EPA M#CAR000171017 <br /> P.O. Box 28-5 Phone: 0`448.3700 U.S.D.O.T.# 1484667 INVOICE # <br /> Vaca%ille.Ca 95696-28-1 Fax: 07-448-3499 D.T.S.C.#3544 Date' <br /> %vw%.-.hazu-asteremovaLcom CA#274461 <br /> SITE ADDRESS _ BILLING/MAILING ADDRESS _ <br /> Customer 'Lii.='I' ' '''' Customer <br /> E.P.A. # r ., Phone <br /> Additional Contacts: <br /> PRODUCT - SERVICE INFORMATION PROPER SHIPPING DESCRIPTION <br /> 14 21 30 • 45 • 60 . 9 . 180 365 W/C WASTE MANIFEST NUMBER QUANTITY UNITS PRICE AMOUNT <br /> CODE <br /> Empty Drums Provide - Remove W 1A2 5g 0 10g ❑ 15g ❑ 30g ❑ 55g❑ S P F <br /> Clor-D-Tec`Q4000 Test Kit: -es':Z1 Pass ❑ Fail ❑ Generator Knowledge ❑ PPM <br /> Trcrsoortetior` Ch•a,ges/Addition, I Truck Time/Additional Labor/ LAB Packing/Site Cleanin <br /> Clear: Y _ ti Labels Cii A/F UOF T`... Oily Debris - <br /> SERVICES REQUESTED BY TAX <br /> We * P. O. # TOTAL CHARGES: <br /> Accept `� .'`� � � • <br /> GENERATOR'S CERTIFICATION: - eov cec'or= -+;-e ecree�'s of teas consignment are fully oral accurately described above by proper shipping name and ore classified,packed,marked,and <br /> :,be c^^ - _- - --- _- Ie,`a-saar o•r hiahv+cy cccording to appFicable state and national government regulations. If I am a large quantity generator,1 certify that I <br /> rc r9 C p•c•g•c-' c-__ _:_c--^e :e_•-,e c c•ax:cit.c'.+os-egenerated to the degree have determined to be economically practicable and that I have selected the practicable methoc <br /> z - T^ri ea'he oresent and future threat to human health and the environment:OR.if I am a small quantity generator.I have made <br /> - - - _ ^^se:ec'*,.eaes +oste r^anoyernent method that is ovoNable tome and that I con afford. All used oil from the generator listed above <br /> -_ .- __- ce S-ve c` "cr^'a c-couce used oii'nlo•ecycied oil OR a facility that is required to comply with Federal regulations applicable to the <br /> s_:oecteo-=7 C,cssecY v ith th,s waste has been disclosed. The customer agrees to pay reasonable costs and attorney <br /> - -= -- - es c= rs coo crit^sno"be fn Solon <br /> countv. I declare under penalty of pZury that the forgoina is true and correct. <br /> DISPO$Ot/RECYCLING FACILITY - -Collection Station Intlustncar Agriculture Government Marine Other Indussa al Lubricating <br /> •- a6:�..- .. - ir, .`.sl`.� .Vrr. f.J c, <br /> r�:=- ..._ ._ -...�r-. . ,. :>';� •+:... _... .. ?�,:�,w,r::,;3., zcr_x�Naa:ma3 ot.,Est <br /> : -.. -" . .^<:. _ :i:, _ ,. .. . . . ..... ,. ,i;.. :f't'';r'ti% '','���rlr'SLi:: •l'vil$1h��^.'�+ <br /> .yam <br /> -• i - 'l tea, 0 <br /> RtiritlVQnle Generators Signa'tore r. Driver's Signature <br /> Stmte Law Requires that you keep this'Recelpt/Bill of Lading on Ole no less than 3 years. <br /> 990/Z00lp1 OKI SOAS ANH AidIONHUd 66b£8b6LOLT XVd £T:9T TTOZ/ZZ/80 <br />