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FRE VMO U EoV lKO1�1MEN IAL VKVIUES, IIN UO <br /> .Send Pa%ment to: Phone: 00-559-3_ 4 EPA ID#CAR000171017 <br /> P.O.Box 38"5 Phone: ,0i-448-3 7001 `' `• '? ^�' <br /> U.S.D.O.T.#1484667 I'vVOICE # <br /> Vacaville.Ca 95696-2875 Fax: M-1-448-3499 D.T.S.C.#3544 <br /> www.hazw•asteremoval.com CA#274461 Date . <br /> SITE ADDRESS BILLING/MAILING ADDRESS <br /> Customer Customer <br /> E.P.A. # Phone <br /> Additional Contacts: <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 /> I <br /> Empty Drums provide Remove 1A1 1A2 5g 0 10g ❑ 15g ❑ 30g ❑ 55g.0•'S P F ` <br /> Cior-D-Tec'Q4004 Tss'Kit: ,es'Z3 ass ❑ Fail ❑ Generator Knowledge ❑ PPM <br /> Transportation Charges/Additional ruck Time/Additional Labor/LAB Packing/Site Cleaning <br /> Clean: Y N Labels Oil A/F UOf Oily Debris <br /> SERVICES REQUESTED BY TAX <br /> We r�. - <br /> Acce t P. O.# TOTAL CHARGES: <br /> GENERATOR'S CERTIFICATION: he ebv deccre tho!t e con!e-ts of this consignmen.'are fully and accurate y described above by proper shipping name and are classified.packed.marked,and <br /> labeled,and ore in cu rescecs:^crocer co^silo.'e trcnspOrt oy IchNc�accordeng to ooprcable state and national government regulations. If I am o large quantity generator,I certify that I <br /> have a prcgec�r Ln p'cce•c'ec.;ce're:c_me c^d" xi,v n':•:csre ge-wc'eo-c`-e cel ee-`,eve deserm;ned to be economically practicable and that I have selected the practicable method <br /> or ea ^e sb are o _so - c::�c_ —e w�c^ri r 7v lz=_c'-e o ese c. Lture mreo'ro t•umcn health and the environment:OR,if I am a small quantity generator,I have made <br /> a gocd. h e"cr• T e ae^ d 5 - ace n - <br /> es a e thca to s ovc Ictre to me and that 1 can afford.Ah used of from the generator listed above <br /> will be!ro^s o e ey _c o! c•oa.:ce::s c recyc ec an OR a facility that is required to compy with Federal regulations applicable io the <br /> manage^^_ 1 0- ssd o e+ •>c� e; a<:c peeled Fczo.ds ossocic!ea with,his waste has been disclosed. The customer agrees to pay reasonable costs and attorney <br /> fees:ncvned 'he o_c c"ca,,, p_r a,eo his obli oho. s c.ae.r Solana county. I declare under penalty of Perjury that the largoina is hue and correct. <br /> DISPOSAVRECYCLING FACILITY: Collection Station industrial Agriculture Govemment Marine Other Industrial Mb—dcating <br /> Oil <br /> U- L47 <br /> .Prll9t Norrie �-• _ � �• _.=��> _�: - - <br /> Gellfate4fi gr<ature Driver's Signature^ <br /> state aw Requires that you keep this Receipt/Big of lading on flue no less than 3 years. <br /> 990/9001p1 ONI SOAS ANB A11OIRHA 66VCRVVLOLT XVA VT:9T TTOZ/ZZ/80 <br />