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FREMOUW E' -VIRONMENTAL SORVICES, INC. <br /> Send Pa%ment To: Phone: 800-559-3:'4 EPA 1D=CAR000171017 <br /> P.O.Box 28?5 Phone: ?0?-448-3?00 li.S.D.O.T. 1484667 INVOICE # <br /> Vaca-ville"Ca 95696-2875 Fax: 707-448-3499 D.T.S.C. 3544 Date - <br /> www.hazwasteremoval.com CA#274461 --SITE ADDRESS BILLING/MAILING ADDRESS <br /> Customer Customer r� <br /> E.P.A. <br /> Phone <br /> Additional Contacts: : <br /> PRODUCT - SERVICE ;N FORMATIONPROPER 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 'A, l A2 5g ❑ I Og ❑ 15g 0 30g ❑ 55g.d S,:P F `; <br /> Clor-D-Tett Q4000 Test Kit: Test❑ Pass 0 Fail ❑ Generator Knowledge ❑ PPM <br /> Transportation Charges/Additional Truck Time/Additions' Labor/LAB Packing/Site Cleaning <br /> Clean: Y. NLabels Oil A/F ` 4; U0= Oily Debris <br /> SERVICES REQUESTED BY TAX N. <br /> We <br /> Acca t P. 0• TOTAL CHARGES: <br /> GENERATOR'S CERTIFICATION: 1 hereby declare that t e contents of this consignment are�uiiy and accuraseiy described above by proper shipping name and are classified,pocked,marked,and <br /> labeled,and are in all respects in proper condition f transport by highway occording to applicable state and national government regulations. If I am a large quantity generator,1 certify that I <br /> have a program in place fo reduce the volume and toxicity of waste generated to the degree!have determined to be economically practicable and that I have selected the practicable method <br /> of treatment,storage,or disposal currently available torn.which minimized the present and future threat to human heo:th and the environment:OR.if I am a small quantity generator,I have made <br /> a good faith effort to minimize my waste generation and select the best waste management method that is aveilobie to me and that I can afford. All used oil from the generator listed above <br /> will be transported only to a facility permitted by the State of Califomio to produce used oil intc recycled oil OR a facility that is required to comply with Federal regulafions applicable to the <br /> management of used oil. AI!relevant informof on regording known or suspected hazards associated with this waste has been disclosed. The customer agrees to pay reasonable costs and attorney <br /> fees incurred in the collection of this obligation Venue for a oses of this obli ation shall be in Solcno county, I declare under penalty of a'u !hot the forgoing is true and correct. <br /> DISPOSAURECYCLING FACILITY: Cdlection Station Industrial Agriculture Government Marine Other Industrial Lubricating <br /> I orl <br /> • f`�',•?,'._Y'•'-1'` '•Y*f 1:Y{9'iY:�'. :.dm:` •,..�'!i/".. _i ..r'I:. -. 4:.... .:.Y�:.Y!.I v,�K•r <br /> Print Nome Gen ators Sign itu 6rs S1 otat?�re <br /> I hereby certify that I have read ci d have the authority to bins tfTe above listed generator to the ter n e reverse side of this form. <br /> 990/vZOp OhII SOAS ANH AnONHUA 66VERVVLOLT XHd 6T :9T TTOZ/ZZ/80 <br />