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V � <br /> CSG SK-SSL-UMO-01 Joseph R Lima 11 01/19/17 14:09 PAGE 1 <br /> Safety-Kleen Systems , Inc . <br /> 2600 N Central Espy, Suite 200 <br /> Richardson, TX 75080 <br /> CORPORATE: 800-669-5140 <br /> 24 HR EMERGENCY: 800-468-1760 (Safety-Kleen) <br /> 2095451011 <br /> REFERENCE NOR. <br /> CUSTUMER* CA47958 Cal-Trans Shop 10- Lodi Cvis 72504741-1700019360 - <br /> 845 E Pine St SWC WEEK: 2017-1 <br /> Lodi CA 95240-3108 SWC DATE: 01/19/17 14:09 <br /> PHONE 209-333-6953 <br /> BILL TO CUSTOMER* BILL TO ADDRESS: <br /> CA47769 Caltrans Cws <br /> Po Box 1632 <br /> Stockton CA 95201-3038 <br /> PHONE 209-948-7815 <br /> PURCHASE ORDER* TAX EXEMPT* <br /> PRODUCT/SERVICES <br /> SERVICE/ TOTAL <br /> PRODUCT QTY UNIT PRICE TAX CHARGE <br /> 10256 FEE, USED OIL STOP CHARGE 1.000 <br /> SERVICE TERM 16 WEEK <br /> 66636 USED OIL NON-PREQUAL SERV 190.000 <br /> SERVICE TERM 16 WEEK <br /> HALOGEN / CLOR-O-TECF TEST RESULT PASS: PPM a 1000 <br /> 66665 ANTIFREEZE QJON-PREQUAL) 35.000 <br /> SERVICE TERM 24 WEEK <br /> HALOGEN / CLOR-D-TMCF FtSI RESULT PASS: PPM < 1000 <br /> k CONIS: I TSUF: tVG MAHIFt5I4: 0058626635KS FORM CD: US SHIP, 221391434 <br /> CNT*: 170119705874 QTY: 35 W17VOL 6 PROF* 156030 SKUOT 651 <br /> ---------------_--------_-----______ <br /> TOTAL SERVICE/PRODUCTS <br /> TOTAL CHARGE <br /> CREDITS <br /> -------`----_- <br /> TOTAL DUE <br /> UNPAID BALANCE THIS RECEIPT <br /> If high risk source, rep. certifies that load specific PCB & Silicon <br /> testing have been completed prior to pmmpiny this load. <br /> GENERATOR STATUS <br /> i SQG/LQG: Vehicle <br /> Customer certifies that (i) the above named nwterials are PrvPerly <br /> classified, pada0ed, narked and labeled, and air in ,.per cmidititin <br /> for transportation accorJimy to the dp'licable ,elulat Nona of the <br /> Department of Tramsp or tatiuo (ii) nof material Jlan9e has uccurred <br /> •ctica •.,..a wavi wbste 4G'tne Oe9i re to ii,eon..'....'._ .........-_ <br /> - econoin ically <br /> practicable. <br /> G <br /> SlUnnture <br /> CUSTOMER / GENERATOR: Cal-Trans Shap 10- Lodi Cws david jhnson <br /> rr I <br /> '•V Slry ldture <br /> TRANSPORTER: Joseph R Lime Jr <br />