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FREMOUVV E* <br /> . YMONMENIAL *RV1U.ES9 "u, <br /> Send Pavrillient to: Phone: WO-5-;9-3— EPA ID#CAPL000 171017 4 t_ 9 <br /> j, <br /> P.O. Box 28-4 Photic: '•0.448-3`00 U.S.D.O.T.#1494667 IN # ,; <br /> Vacai-ille.Ca 95696-2815 Fax: 07-448-3499 D.T.S.C.#3544 'Z i <br /> %-A-%--.bazwastercxnova1.com CA#274461 Date S"'; <br /> SITE ADDRESS <br /> BILLING/MAILING APQRESS Millie <br /> Customer i4rannon i re Customer <br /> V, %-i X <br /> A <br /> E.P.A. Phone <br /> Additional Contacts: <br /> PRODUCT - SERVICE INFORMATION PROPER SHIPPING DESCRIPTION <br /> 7 14 21 30 45 60 90 180 WASTE 365 W/C CODE MANIFEST NUMBER QUANTITY UNITS PRICE AMOUNT <br /> 7 <br /> p. <br /> Emp`y Dr-irrs Provide Remove 1 A 1 A,2 5g ZI I Og El 15g ZI 30g 0 55g LJ S P F <br /> Clor-D-Tect Q4000 Test Kit: Test 0 Pass -ZI Fail C) Generator Knowledge U PPM <br /> Transportation Charges/Additional Truck Time/Additional Labor/LAB Pocking/Site Cleaning <br /> Clean: • Y,-.. N Labels A/F UOF <br /> Oily Debt <br /> SERVICES REQUESTED BY TAX <br /> We <br /> .12"et P. O.# TOTAL CHARGES: <br /> GENERATOR'S CERTIFICATION: ne,st.-necc,e*---':.econ,eniio;iris cors;2-lrner,.! re'ui:y and accurately described above by proper shipping name and are clossified,packed.marked,and <br /> lobeiec.arc c,e!�a;!-Ss2e-;i -n,_-:e-cc-a'e:c-'c,:r_-rspor,ov�hwcy occcrdinioto applicable state and national government regulations- if i am a large quantity generator,I certify that I <br /> 'ogr_-!n place c <br /> have c iee'he c-Me C-d Z)C& Cfwaste generated to the degree i have determined to be economically practicable and that I have selected the practicable methoc <br /> of treatment.storage.or disposal currently available 'a me which minimized the present and future threat to human health and the environment;OR,if I am a smoll quantity generator.I have mod( <br /> a good faith effort to minimize my waste generation ond select the best waste monagement method that is available to me and that I con afford. AN used oil from the generator listed above <br /> only to a fac; <br /> will be transported .1itypemitted by the Slate of California to produce used oil into recycled ON OR a facility that is required to comply with Federal regulations applicable to the <br /> managernert of used oil.All relevant information ret;arding krown or suspected hazards associated with this waste has been disclosed. The customer agrees to pay reasonable costs and attorney <br /> fees incurred in the coilectior.of Ws obligation. Ven e for purposes of this obffgction shoN o county. I declare under penalty of ndury!hot the forgoing is true and correct. <br /> DISPOSAL/RECYCLING FACILITY: Collection Station k1ri�_ju_sfrIaIjAgriculture Governmentstrial Lubd�crtlnij <br /> marine Other Indu <br /> I <br /> fi. on ON <br /> j <br /> t L f:F:%i Rao.-.. <br /> RrA-d n Or.Lea. <br /> jF, 'A MR,j: <br /> Hy. <br /> -1 5'i`- ZP V-3111sam <br /> ell <br /> Generdt6ls S ture, Driver's Signature <br /> State low Requires that you keep this Receipt/Bill of Lading on flie no less than 3 years. <br /> 990/500 11 ON1 SOAS ANH AflIONRUA 666E86VLOLT XVJ VT :9T TTOZ/ZZ/90 <br />