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FRE N 10 U NN E �V1 R ONN MEQ TAL $6R.V 10ES9 INC,
<br /> F r,;r D=C -�,K4GO1-: 1- 26924
<br /> n\ _€-: - - f i S.D.O. ;146E- I VOICE #
<br /> P.O. S
<br /> aca�lite. Ca 9�b96-_R �.,•, "iJ -µ:-,:�� D.T.S.C. 3-544 Date
<br /> u-a,,-,.hazAastere>✓'ovai,com CA:!!"4451
<br /> SITE ADDRESS BILLING/MAILING ADDRESS
<br /> Customer _�raMOfl TirIP _ Customer—Brannon Tim
<br /> 4905 Claremoni Avenue P.O. Box 1988
<br /> Stockton, CA 91,5207 Stockton, CA 95201
<br /> E.P.A. ziCALLID-0- Phone
<br /> Additionai Contacts: 209 4 7"9000
<br /> PRODUCT - SERVICE INFORMATION PROPER SHIPPING DESCRIPTION
<br /> • '; 2'. su 45 5D i0 13 365 V; C 'NA5'E MAN
<br /> IF'cST NUMBER QUANTITY UNITS PRICE AMOUNT
<br /> CODE
<br /> ;�or�i-RCRA Hazardous Waste Liquid(Used Oil) SCA 221 (,yo7(��6
<br /> Non-RCRA Hazardous Waste Liquid (Used Ant�Freeze) CA 134 _ 1.00
<br /> Nor,RCR.A Hazardous Waste Liquid(Oily Water) ;CA 223
<br /> Drained Used Oli /Gasoline/ Diesel Ffters j N/A 55.00
<br /> NorFRCRA Hazaroous Waste Sold(CH Cordarrv-ded Debris,Sod) CA 223
<br /> Parts Washer Serme ;CA 223
<br /> Non-RCRA Hazardous Waste Liquid(Brake Fluid) ICA 343
<br /> Waste Flammaik Lq.Ad, N.O.S. 3, UN1993. PGII (Gasoline-Diesel) 1/0018
<br /> I
<br /> En-:pt,i Drjrns P,c 'ce = Re^-:ove — A' ' 42 5g :1 'Oc Z) 15g D 30g 55g O S P F
<br /> C'.ofr-D--ec, 04:0 -es` <'-: -ez- :I Pass D rci :I Generator Knowledge J PPM
<br /> Transporra'ior: C-,c-ges/Acc'tonol 7,uck lime/Additional Labor/ LAB Packing/Site Cleaning
<br /> Cleo-,: % N O`l U A/r rUOF Y, �F Oily Debris j/Z cii4-j
<br /> SERVICES REQUESTED BY iTAX
<br /> f,o
<br /> Acca t ® P. O. # TOTAL CHARGES:
<br /> GENERATOR'S CERTIFICATION: -rereb,de_c•e -c7 _ --- __cn5:z ssns cr.4.::,c;-,G occc•;'el:descroed dcave[Dy prooer shipping norne and are classified,packed,marked,and
<br /> labeled.one are in oil respecu;n c:ope�ccndaier.is srcnscc-oy mgr•wcy ccco,Aing ro oopliccble sore cnc no�;onel government regulations. f I am a large quortity generator.I certify that I
<br /> have a program in place to reduce the vo'_me cnd oxiciry of wosle generated to the cegree I hove oeter^ired to be economically procticoble and that I have selected the practicable methoc
<br /> of treatment,storoge,or disposal curer-,y cva`lable o me wrich rnmimiied the aresew and Future threat is human health and the environment;OR,it I am a small quantity generator.I have mod(
<br /> a good faith effort to minimize my ,oste generafion 4 ird select The bes*waste manogemenr melhco ft of is available to me and that,I can af`ord. All used oil from the generator listed above
<br /> will be transported only Ic c focilify pe•r^f1r1ed by'he State e`Cc`for^`c to adduce.;sec c,7!;,-.-,o•-cycled oil OR o facility that is reauired to comply with Federal regulations ooplicable to the
<br /> mondgemert of used e e c or 0-''c a b a^g<r. .•:n c:sc -.::c - e +:!r s woste has been disclosed. the customer agrees to pay reasonable costs and attorney
<br /> fees ink real in the co-lection of "'s o rzu!ic'. ve^.ue for pun ose<or'n s col.co!'or s-o'.a .,o,c me co„ ,declare under penalty of perjury that the forgoing is true and correct.
<br /> DI OSAL/RECYCLING FACILITY: Collection Station Industrial Agriculture Government I Marine Other Industrot Lubricating
<br /> OII it
<br /> Evergreen 04 Irx.-Davis ! I Evotgreen Oil,Iac [ ]Clean Ha 19 an Jose LLC [ ]Big Sky ErNimitmerlial [ 1211A Cwijry EMI
<br /> 1 Road 306 68M Sm4)Ave 021 dad 401 W Channel Road 2095 Newlands Or.,Ea91
<br /> 1 Days,CA 95616 2 Newark CA 3!560 Jose,t:A 1C+ 4 Benicia,CA 94510 5 Femley,NV 89406
<br /> 510.795-44OG CAD 982446374 510-7954400 CAD 980687418 1 62 0 0594,94310 510.541-2128 CAL OOM 775575-2760 NVD
<br /> Print Name Generator ature, Driver's Signature
<br /> I hereby certify thatority s I have read and hove the authto bind the above listed generator to the termon the reverse side of this form.
<br /> 990/9V0[A ONI SOAS ANFI MIIONHHA 66VURVVLOLT XVd 9Z:9T T10Z/ZZ/80
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